Journal: JACC Cardiovasc Imaging

Sorted by: date / impact
Abstract

Prognostic Significance of Cardiac I-MIBG SPECT Imaging in Heart Failure Patients With Preserved Ejection Fraction.

Seo M, Yamada T, Tamaki S, Watanabe T, ... Sakata Y, Fukunami M
Objectives
The authors sought to elucidate the prognostic value of cardiac sympathetic nerve dysfunction as evaluated using iodine-123-labeled metaiodobenzylguanidine (123I-MIBG) single-photon emission computed tomography (SPECT) imaging in patients with heart failure (HF) with preserved left ventricular ejection fraction (HFpEF).
Background
Cardiac sympathetic nerve dysfunction assessed by 123I-MIBG imaging is associated with poor outcomes in chronic HF patients with reduced left ventricular ejection fraction (HFrEF). However, no information is available on the prognostic vale of cardiac 123I-MIBG SPECT imaging in patients with HFpEF.
Methods
We studied 148 patients admitted for acute decompensated HF (ADHF) with nonischemic HFpEF and who underwent cardiac 123I-MIBG imaging at discharge. The cardiac 123I-MIBG heart-to-mediastinum ratio (H/M) was measured on the delayed planar image (late H/M). SPECT analysis of the delayed image was conducted, and the tracer uptake in all 17 regions on the polar map was scored on a 5-point scale by comparison with a sex-matched normal control database. The total defect score (TDS) was calculated by summing the score of each of the 17 segments. The primary endpoint was the association between TDS and cardiac events (the composite of emergent HF hospitalization and cardiac death).
Results
During a mean follow-up period of 2.4 ± 1.6 years, 61 patients experienced cardiac events. TDS was significantly associated with cardiac events after multivariate Cox adjustment (P < 0.0001). Patients with high TDS levels had a significantly greater risk of cardiac events than those with middle or low TDS levels (63% vs 40% vs 20%, respectively; P < 0.0001; HR: 4.69; 95% CI: 2.29 to 9.61; and HR: 2.46; 95% CI: 1.14 to 5.29). C-statistic of TDS was 0.730 (95% CI: 0.651 to 0.799), which was significantly higher than that of late H/M (0.607; 95% CI: 0.524 to 0.686; P = 0.0228).
Conclusions
Cardiac 123I-MIBG SPECT imaging provided useful prognostic information in nonischemic ADHF patients with HFpEF. (Clinical Trial: Osaka Prefectural Acute Heart Failure Syndrome Registry (OPAR): UMIN 000015246).

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Seo M, Yamada T, Tamaki S, Watanabe T, ... Sakata Y, Fukunami M
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656490
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prognostic Value of Computed Tomography-Derived Fractional Flow Reserve Comparison With Myocardial Perfusion Imaging.

Ahmed AI, Han Y, Al Rifai M, Alnabelsi T, ... Mahmarian JJ, Al-Mallah MH
Objectives
The aim of this study was to compare the incremental prognostic value of coronary computed tomography (CT) angiography (CCTA)-derived machine learning fractional flow reserve CT (ML-FFRct) versus that of ischemia detected on single-photon emission-computed tomography (SPECT) myocardial perfusion imaging (MPI) on incident cardiovascular outcomes.
Background
SPECT MPI and ML-FFRct are noninvasive tools that can assess the hemodynamic significance of coronary atherosclerotic disease.
Methods
We studied a retrospective cohort of consecutive patients who underwent clinically indicated CCTA and SPECT MPI. ML-FFRct was computed using a ML prototype. The primary outcome was all-cause mortality and nonfatal myocardial infarction (D/MI), and the secondary outcome was D/MI and unplanned revascularization, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) occurring more than 90 days postimaging. Multiple nested multivariate cox regression was used to model a scenario wherein an initial anatomical assessment was followed by a functional assessment.
Results
A total of 471 patients (mean age: 64 ± 13 year; 53% males) were included. Comorbidities were prevalent (78% hypertension, 66% diabetes, 81% dyslipidemia). ML-FFRct was <0.8 in at least 1 proximal/midsegment was present in 41.6% of patients, and ischemia on MPI was present in 13.8%. After a median follow-up of 18 months, 7% of patients (n = 33) experienced D/MI. On multivariate Cox proportional analysis, the presence of ischemia on MPI but not ML-FFRct significantly predicted D/MI (HR: 2.3; 95% CI: 1.0-5.0; P = 0.047; or HR: 0.7; 95% CI: 0.3-1.4; P = 0.306 respectively) when added to CCTA obstructive stenosis. Furthermore, the model with SPECT ischemia had higher global chi-square result and significantly improved reclassification. Results were similar using the secondary outcome and on several sensitivity analyses.
Conclusions
In a high-risk patient cohort, SPECT MPI but not ML-FFRct adds independent and incremental prognostic information to CCTA-based anatomical assessment and clinical risk factors in predicting incident outcomes.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Ahmed AI, Han Y, Al Rifai M, Alnabelsi T, ... Mahmarian JJ, Al-Mallah MH
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656489
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Air Pollution and Coronary Plaque Vulnerability and Instability: An Optical Coherence Tomography Study.

Montone RA, Camilli M, Russo M, Termite C, ... Crea F, Niccoli G
Objectives
We assessed the relationship between exposure to air pollutants and mechanisms of coronary instability evaluated by optical coherence tomography (OCT) in patients with acute coronary syndrome (ACS).
Background
Air pollution is an emerging key player in determining the residual risk of coronary events. However, pathophysiological mechanisms linking air pollution and coronary events have been not adequately investigated.
Methods
Patients with ACS undergoing OCT imaging were retrospectively selected. Mechanism of culprit lesion instability was classified as plaque rupture (PR) or intact fibrous cap (IFC) by OCT, and the presence of macrophage infiltrates (MØI) and thin-cap fibroatheroma (TCFA) at the culprit site was also assessed. Based on each case\'s home address, exposure to several pollutants was evaluated, including particulate matter 2.5 (PM2.5), PM10, and carbon monoxide (CO). Only patients with >2 years of available data on air pollution exposure prior to ACS were enrolled.
Results
We included 126 patients (median age: 67.0 years of age; interquartile range: 55.5-76.0; 97 male patients [77.0%]). Sixty-six patients (52.4%) had PR as the mechanism of plaque instability. Patients with PR were exposed to significantly higher PM2.5 levels than to IFC, and PM2.5 was independently associated with PR (odds ratio: 1.194; 95% CI: 1.036 to 1.377; P = 0.015). Moreover, exposure to higher levels of PM2.5 was independently associated with the presence of TCFA and of MØI at the culprit site. Interestingly, PM2.5, PM10, and Co levels were positively and significantly correlated with serum levels of C-reactive protein.
Conclusions
We provide novel insights into the missing link between air pollution and increased risk of coronary events. In particular, exposure to higher concentrations of air pollutants is associated with the presence of vulnerable plaque features and with plaque rupture as a mechanism of coronary instability. An enhanced systemic and plaque inflammatory activation may explain these findings.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Montone RA, Camilli M, Russo M, Termite C, ... Crea F, Niccoli G
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656488
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Comparison of Different Investigation Strategies to Defer Cardiac Testing in Patients With Stable Chest Pain.

Zhou J, Li C, Cong H, Duan L, ... Chen Y, Guo Z
Objectives
This study aimed to compare the current 5 investigation strategies to defer cardiac testing in patients with stable chest pain.
Background
For the clinical management of stable chest pain, the identification of patients unlikely to benefit from further cardiac testing is important, but the most appropriate investigation strategy is unknown.
Methods
A total of 4,207 patients referred to coronary computed tomography angiography for stable chest pain were classified into low- and high-risk groups according to the 2016 National Institute of Health and Care Excellence (NICE) guideline-determined strategy; PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) minimal risk tool-based strategy; 2019 European Society of Cardiology (ESC) guideline-determined strategy; and coronary artery calcium score (CACS), either in isolation (the CACS strategy) or as part of a weighted clinical likelihood model-based strategy (the CACS-CL strategy). The associations of obstructive coronary artery disease on coronary computed tomography angiography, major adverse cardiovascular events, and subsequent clinical management with risk groups according to different strategies were evaluated and compared.
Results
The NICE, PROMISE, ESC, CACS, and CACS-CL strategies classified a proportion (22.63%, 29.21%, 41.84%, 46.76%, and 51.41%, respectively) of patients into low-risk groups. Compared with the NICE, PROMISE, ESC, and CACS strategies, the CACS-CL strategy had a stronger association between risk groups and obstructive coronary artery disease (odd ratios: 16.00 vs 2.93, 5.53, 7.94, and 10.39, respectively), major adverse cardiovascular events (HRs: 6.83 vs 1.90, 2.94, 4.23, and 5.13, respectively) and intensive subsequent clinical management as well as better metrics of diagnostic accuracy and positive net reclassification improvement.
Conclusions
Among contemporary strategies used to identify patients with stable chest pain at low risk, the use of CACS, especially when combined with clinical risk features, showed the strongest potential to effectively defer cardiac testing.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Zhou J, Li C, Cong H, Duan L, ... Chen Y, Guo Z
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656487
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Left Atrial Strain Determinants During the Cardiac Phases.

Mălăescu GG, Mirea O, Capotă R, Petrescu AM, Duchenne J, Voigt JU
Objectives
The present study investigated the determinants of left atrial (LA) strain in all phases of the cardiac cycle.
Background
LA strain by speckle-tracking echocardiography allows the assessment of LA function in each phase of the cardiac cycle. However, its determinants and its relation with left ventricular (LV) function have not yet been fully described.
Methods
The authors performed a retrospective analysis in 127 patients with different cardiovascular pathologies. Using 2-dimensional speckle tracking in 4- and 2-chamber apical views we derived both LA and LV strain curves. Strain-strain loops were reconstructed using LV strain and the corresponding, synchronized LA strain data. Linear regressions were calculated for the entire strain-strain loop as well as for the 3 phases of the cardiac cycle (systole, and early and late diastole). The association between LA strain parameters and LV systolic and diastolic parameters was studied. The prediction of cardiovascular events was evaluated for both measured and predicted LA strain and other parameters.
Results
LA and LV strain curves presented excellent correlations with an R2 >0.9 for the cardiac cycle, and >0.97 for its phases. Moreover, the ratios of LV/LA maximal volumes and the slopes of the LA-LV strain-strain loops of the individual patients correlated well (R2 = 0.75). In each phase of the cardiac cycle, LA strain parameters correlated well with the corresponding LV strain and the LV-LA volume ratio (R2 >0.78). No significant difference in predictive ability of cardiovascular events or atrial fibrillation between the measured and predicted LA strain was observed (P > 0.05 for both).
Conclusions
In the absence of abnormal LA/LV volume exchange, LA strain is, to a large extent, determined by LV strain and further modulated by the ratio of LV and LA volumes. Nonetheless, measuring LA strain is of high clinical interest because it integrates several parameters into a single, robust, and reproducible measurement.

Copyright © 2021. Published by Elsevier Inc.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Mălăescu GG, Mirea O, Capotă R, Petrescu AM, Duchenne J, Voigt JU
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656486
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Contrast Ultrasound, Sonothrombolysis and Sonoperfusion in Cardiovascular Disease: Shifting to Theragnostic Clinical Trials.

El Kadi S, Porter TR, Verouden NJW, van Rossum AC, Kamp O
Contrast ultrasound has a variety of applications in cardiovascular medicine, both in diagnosing cardiovascular disease as well as providing prognostic information. Visualization of intravascular contrast microbubbles is based on acoustic cavitation, the characteristic oscillation that results in changes in the reflected ultrasound waves. At high power, this acoustic response generates sufficient shear that is capable of enhancing endothelium-dependent perfusion in atherothrombotic cardiovascular disease (sonoperfusion). The oscillation and collapse of microbubbles in response to ultrasound also induces microstreaming and jetting that can fragment thrombus (sonothrombolysis). Several preclinical studies have focused on identifying optimal diagnostic ultrasound settings and treatment regimens. Clinical trials have been performed in acute myocardial infarction, stroke, and peripheral arterial disease often with improved outcome. In the coming years, results of ongoing clinical trials along with innovation and improvements in sonothrombolysis and sonoperfusion will determine whether this theragnostic technique will become a valuable addition to reperfusion therapy.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
El Kadi S, Porter TR, Verouden NJW, van Rossum AC, Kamp O
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656483
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cardiovascular Magnetic Resonance for Patients With COVID-19.

Petersen SE, Friedrich MG, Leiner T, Elias MD, ... Schulz-Menger J, Bluemke DA
COVID-19 is associated with myocardial injury caused by ischemia, inflammation, or myocarditis. Cardiovascular magnetic resonance (CMR) is the noninvasive reference standard for cardiac function, structure, and tissue composition. CMR is a potentially valuable diagnostic tool in patients with COVID-19 presenting with myocardial injury and evidence of cardiac dysfunction. Although COVID-19-related myocarditis is likely infrequent, COVID-19-related cardiovascular histopathology findings have been reported in up to 48% of patients, raising the concern for long-term myocardial injury. Studies to date report CMR abnormalities in 26% to 60% of hospitalized patients who have recovered from COVID-19, including functional impairment, myocardial tissue abnormalities, late gadolinium enhancement, or pericardial abnormalities. In athletes post-COVID-19, CMR has detected myocarditis-like abnormalities. In children, multisystem inflammatory syndrome may occur 2 to 6 weeks after infection; associated myocarditis and coronary artery aneurysms are evaluable by CMR. At this time, our understanding of COVID-19-related cardiovascular involvement is incomplete, and multiple studies are planned to evaluate patients with COVID-19 using CMR. In this review, we summarize existing studies of CMR for patients with COVID-19 and present ongoing research. We also provide recommendations for clinical use of CMR for patients with acute symptoms or who are recovering from COVID-19.

Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Petersen SE, Friedrich MG, Leiner T, Elias MD, ... Schulz-Menger J, Bluemke DA
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656482
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Hybrid Cardiac Magnetic Resonance/Fluorodeoxyglucose Positron Emission Tomography to Differentiate Active From Chronic Cardiac Sarcoidosis.

Greulich S, Gatidis S, Gräni C, Blankstein R, ... la Fougère C, Krumm P
Objectives
The purpose of this study was to investigate the diagnostic value of simultaneous hybrid cardiac magnetic resonance (CMR) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) for detection and differentiation of active (aCS) from chronic (cCS) cardiac sarcoidosis.
Background
Late gadolinium enhancement (LGE) CMR and FDG-PET are both established imaging techniques for the detection of CS. However, there are limited data regarding the value of a comprehensive simultaneous hybrid CMR/FDG-PET imaging approach that includes CMR mapping techniques.
Methods
Forty-three patients with biopsy-proven extracardiac sarcoidosis (median age: 48 years, interquartile range: 37-57 years, 65% male) were prospectively enrolled for evaluation of suspected CS. After dietary preparation for suppression of myocardial glucose metabolism, patients were evaluated on a 3-T hybrid PET/MR scanner. The CMR protocol included T1 and T2 mapping, myocardial function, and LGE imaging. We assumed aCS if PET and CMR (ie, LGE or T1/T2 mapping) were both positive (PET+/CMR+), cCS if PET was negative but CMR was positive (PET-/CMR+), and no CS if patients were CMR negative regardless of PET findings.
Results
Among the 43 patients, myocardial glucose uptake was suppressed successfully in 36 (84%). Hybrid CMR/FDG-PET revealed aCS in 13 patients (36%), cCS in 5 (14%), and no CS in 18 (50%). LGE was present in 14 patients (39%); T1 mapping was abnormal in 10 (27%) and T2 mapping abnormal in 2 (6%). CS was diagnosed based on abnormal T1 mapping in 4 out of 18 CS patients (22%) who were LGE negative. PET FDG uptake was present in 17 (47%) patients.
Conclusions
Comprehensive simultaneous hybrid CMR/FDG-PET imaging is useful for the detection of CS and provides additional value for identifying active disease. Our results may have implications for enhanced diagnosis as well as improved identification of patients with aCS in whom anti-inflammatory therapy may be most beneficial.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Greulich S, Gatidis S, Gräni C, Blankstein R, ... la Fougère C, Krumm P
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656480
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Virtual and Augmented Reality in Cardiovascular Care: State-of-the-Art and Future Perspectives.

Jung C, Wolff G, Wernly B, Bruno RR, ... Bhatt DL, Kelm M
Applications of virtual reality (VR) and augmented reality (AR) assist both health care providers and patients in cardiovascular education, complementing traditional learning methods. Interventionalists have successfully used VR to plan difficult procedures and AR to facilitate complex interventions. VR/AR has already been used to treat patients, during interventions in rehabilitation programs and in immobilized intensive care patients. There are numerous additional potential applications in the catheterization laboratory. By using AR, interventionalists could combine visual fluoroscopy information projected and registered on the patient body with data derived from preprocedural imaging and live fusion of different imaging modalities such as fluoroscopy with echocardiography. Persistent technical challenges to overcome include the integration of different imaging modalities into VR/AR and the harmonization of data flow and interfaces. Cybersickness might exclude some patients and users from the potential benefits of VR/AR. Critical ethical considerations arise in the application of VR/AR in vulnerable patients. In addition, digital applications must not distract physicians from the patient. It is our duty as physicians to participate in the development of these innovations to ensure a virtual health reality benefit for our patients in a real-world setting. The purpose of this review is to summarize the current and future role of VR and AR in different fields within cardiology, its challenges, and perspectives.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Jung C, Wolff G, Wernly B, Bruno RR, ... Bhatt DL, Kelm M
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656478
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

AI Based CMR Assessment of Biventricular Function: Clinical Significance of Intervendor Variability and Measurement Errors.

Wang S, Patel H, Miller T, Ameyaw K, ... Mor-Avi V, Patel AR
Objectives
The aim of this study was to determine whether left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) and left ventricular mass (LVM) measurements made using 3 fully automated deep learning (DL) algorithms are accurate and interchangeable and can be used to classify ventricular function and risk-stratify patients as accurately as an expert.
Background
Artificial intelligence is increasingly used to assess cardiac function and LVM from cardiac magnetic resonance images.
Methods
Two hundred patients were identified from a registry of individuals who underwent vasodilator stress cardiac magnetic resonance. LVEF, LVM, and RVEF were determined using 3 fully automated commercial DL algorithms and by a clinical expert (CLIN) using conventional methodology. Additionally, LVEF values were classified according to clinically important ranges: <35%, 35% to 50%, and ≥50%. Both ejection fraction values and classifications made by the DL ejection fraction approaches were compared against CLIN ejection fraction reference. Receiver-operating characteristic curve analysis was performed to evaluate the ability of CLIN and each of the DL classifications to predict major adverse cardiovascular events.
Results
Excellent correlations were seen for each DL-LVEF compared with CLIN-LVEF (r = 0.83-0.93). Good correlations were present between DL-LVM and CLIN-LVM (r = 0.75-0.85). Modest correlations were observed between DL-RVEF and CLIN-RVEF (r = 0.59-0.68). A >10% error between CLIN and DL ejection fraction was present in 5% to 18% of cases for the left ventricle and 23% to 43% for the right ventricle. LVEF classification agreed with CLIN-LVEF classification in 86%, 80%, and 85% cases for the 3 DL-LVEF approaches. There were no differences among the 4 approaches in associations with major adverse cardiovascular events for LVEF, LVM, and RVEF.
Conclusions
This study revealed good agreement between automated and expert-derived LVEF and similarly strong associations with outcomes, compared with an expert. However, the ability of these automated measurements to accurately classify left ventricular function for treatment decision remains limited. DL-LVM showed good agreement with CLIN-LVM. DL-RVEF approaches need further refinements.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Wang S, Patel H, Miller T, Ameyaw K, ... Mor-Avi V, Patel AR
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656471
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Relationship of Mechanical Dyssynchrony and LV Remodeling With Improvement of Mitral Regurgitation After CRT.

Michalski B, Stankovic I, Pagourelias E, Ciarka A, ... Cvijic M, Voigt JU
Objectives
The aim of this study was to explore the association between mechanical dyssynchrony of the left ventricle before cardiac resynchronization therapy (CRT) and improvement of mitral regurgitation (MR) after CRT.
Background
MR is very frequent among patients with dilated cardiomyopathy and conduction delay.
Methods
Echocardiograms (pre-CRT and 12 ± 3.8 months thereafter) of 314 patients with dilated cardiomyopathy and any degree of MR, who underwent CRT device implantation according to guidelines, were analyzed. Left ventricular (LV) mechanical dyssynchrony was assessed by apical rocking (ApRock) and septal flash (SF), while MR severity was graded from I to IV on the basis of vena contracta width, regurgitation jet size, and proximal isovelocity surface area.
Results
At baseline, 30% of patients presented with severe MR (grade III or IV). In 62% of patients, MR decreased after CRT, and these patients more frequently had left bundle branch block, had more severe MR, had more dilated left ventricles, had lower ejection fractions, and more often had ApRock and SF. Reverse remodeling was more frequent among patients with MR reduction (ΔLV end-systolic volume -35.5% ± 27.2% vs -4.1% ± 33.2%; P < 0.001). In a multivariable logistic stepwise regression, only ApRock (odds ratio [OR]: 3.8; 95% CI: 1.7-8.5; P = 0.001), SF (OR: 3.6; 95% CI: 1.6-7.9; P = 0.002), and baseline MR (OR: 1.4; 95% CI: 1.0-1.9; P = 0.046) remained significantly associated with MR reduction.
Conclusions
ApRock, SF, and severity of MR at baseline are strongly associated with MR reduction after CRT, while LV reverse remodeling is its underlying mechanism. Therefore, in patients with heart failure with LV dyssynchrony on optimal medical treatment, CRT should be the primary treatment attempt for relevant MR.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Michalski B, Stankovic I, Pagourelias E, Ciarka A, ... Cvijic M, Voigt JU
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656470
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Detection and Characterization of Thrombosis in Humans Using Fibrin-Targeted Positron Emission Tomography and Magnetic Resonance.

Izquierdo-Garcia D, Désogère P, Philip AL, Mekkaoui C, ... Caravan P, Sosnovik DE
Objectives
The authors present a novel technique to detect and characterize LAA thrombus in humans using combined positron emission tomography (PET)/cardiac magnetic resonance (CMR) of a fibrin-binding radiotracer, [64Cu]FBP8.
Background
The detection of thrombus in the left atrial appendage (LAA) is vital in the prevention of stroke and is currently performed using transesophageal echocardiography (TEE).
Methods
The metabolism and pharmacokinetics of [64Cu]FBP8 were studied in 8 healthy volunteers. Patients with atrial fibrillation and recent TEEs of the LAA (positive n = 12, negative n = 12) were injected with [64Cu]FBP8 and imaged with PET/CMR, including mapping the longitudinal magnetic relaxation time (T1) in the LAA.
Results
[64Cu]FBP8 was stable to metabolism and was rapidly eliminated. The maximum standardized uptake value (SUVMax) in the LAA was significantly higher in the TEE-positive than TEE-negative subjects (median of 4.0 [interquartile range (IQR): 3.0-6.0] vs 2.3 [IQR: 2.1-2.5]; P < 0.001), with an area under the receiver-operating characteristic curve of 0.97. An SUVMax threshold of 2.6 provided a sensitivity of 100% and specificity of 84%. The minimum T1 (T1Min) in the LAA was 970 ms (IQR: 780-1,080 ms) vs 1,380 ms (IQR: 1,120-1,620 ms) (TEE positive vs TEE negative; P < 0.05), with some overlap between the groups. Logistic regression using SUVMax and T1Min allowed all TEE-positive and TEE-negative subjects to be classified with 100% accuracy.
Conclusions
PET/CMR of [64Cu]FBP8 is able to detect acute as well as older platelet-poor thrombi with excellent accuracy. Furthermore, the integrated PET/CMR approach provides useful information on the biological properties of thrombus such as fibrin and methemoglobin content. (Imaging of LAA Thrombosis; NCT03830320).

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Izquierdo-Garcia D, Désogère P, Philip AL, Mekkaoui C, ... Caravan P, Sosnovik DE
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656469
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Predicting Survival in Repaired Tetralogy of Fallot: A Lesion-Specific and Personalized Approach.

Ghonim S, Gatzoulis MA, Ernst S, Li W, ... Pennell DJ, Babu-Narayan SV
Objectives
We sought to identify patients with repaired tetralogy of Fallot (rTOF) at high risk of death and malignant ventricular arrhythmia (VA).
Background
To date there is no robust risk stratification scheme to predict outcomes in adults with rTOF.
Methods
Consecutive patients were prospectively recruited for late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) to define right and left ventricular (RV, LV) fibrosis in addition to proven risk markers.
Results
The primary endpoint was all-cause mortality. Of the 550 patients (median age 32 years, 56% male), 27 died (mean follow-up 6.4 ± 5.8; total 3,512 years). Mortality was independently predicted by RVLGE extent, presence of LVLGE, RV ejection fraction ≤47%, LV ejection fraction ≤55%, B-type natriuretic peptide ≥127 ng/L, peak exercise oxygen uptake (V02) ≤17 mL/kg per minute, prior sustained atrial arrhythmia, and age ≥50 years. The weighted scores for each of the preceding independent predictors differentiated a high-risk subgroup of patients with a 4.4%, annual risk of mortality (area under the curve [AUC]: 0.87; P < 0.001). The secondary endpoint (VA), a composite of life-threatening sustained ventricular tachycardia/resuscitated ventricular fibrillation/sudden cardiac death occurred in 29. Weighted scores that included several predictors of mortality and RV outflow tract akinetic length ≥55 mm and RV systolic pressure ≥47 mm Hg identified high-risk patients with a 3.7% annual risk of VA (AUC: 0.79; P < 0.001) RVLGE was heavily weighted in both risk scores caused by its strong relative prognostic value.
Conclusions
We present a score integrating multiple appropriately weighted risk factors to identify the subgroup of patients with rTOF who are at high annual risk of death who may benefit from targeted therapy.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Ghonim S, Gatzoulis MA, Ernst S, Li W, ... Pennell DJ, Babu-Narayan SV
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656466
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Using Deep-Learning Algorithms to Simultaneously Identify Right and Left Ventricular Dysfunction From the Electrocardiogram.

Vaid A, Johnson KW, Badgeley MA, Somani SS, ... Nadkarni GN, Glicksberg BS
Objectives
This study sought to develop DL models capable of comprehensively quantifying left and right ventricular dysfunction from ECG data in a large, diverse population.
Background
Rapid evaluation of left and right ventricular function using deep learning (DL) on electrocardiograms (ECGs) can assist diagnostic workflow. However, DL tools to estimate right- ventricular (RV) function do not exist, whereas those to estimate left ventricular (LV) function are restricted to quantification of very low LV function only.
Methods
A multicenter study was conducted with data from 5 New York City hospitals: 4 for internal testing and 1 serving as external validation. We created novel DL models to classify left ventricular ejection fraction (LVEF) into categories derived from the latest universal definition of heart failure, estimate LVEF through regression, and predict a composite outcome of either RV systolic dysfunction or RV dilation.
Results
We obtained echocardiogram LVEF estimates for 147,636 patients paired to 715,890 ECGs. We used natural language processing (NLP) to extract RV size and systolic function information from 404,502 echocardiogram reports paired to 761,510 ECGs for 148,227 patients. For LVEF classification in internal testing, area under curve (AUC) at detection of LVEF ≤40%, 40% < LVEF ≤50%, and LVEF >50% was 0.94 (95% CI: 0.94-0.94), 0.82 (95% CI: 0.81-0.83), and 0.89 (95% CI: 0.89-0.89), respectively. For external validation, these results were 0.94 (95% CI: 0.94-0.95), 0.73 (95% CI: 0.72-0.74), and 0.87 (95% CI: 0.87-0.88). For regression, the mean absolute error was 5.84% (95% CI: 5.82%-5.85%) for internal testing and 6.14% (95% CI: 6.13%-6.16%) in external validation. For prediction of the composite RV outcome, AUC was 0.84 (95% CI: 0.84-0.84) in both internal testing and external validation.
Conclusions
DL on ECG data can be used to create inexpensive screening, diagnostic, and predictive tools for both LV and RV dysfunction. Such tools may bridge the applicability of ECGs and echocardiography and enable prioritization of patients for further interventions for either sided failure progressing to biventricular disease.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Vaid A, Johnson KW, Badgeley MA, Somani SS, ... Nadkarni GN, Glicksberg BS
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656465
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Coronary Calcium to Rule Out Obstructive Coronary Artery Disease in Patients With Acute Chest Pain.

Grandhi GR, Mszar R, Cainzos-Achirica M, Rajan T, ... Cury RC, Nasir K
Objectives
This study aimed to evaluate the ability of coronary artery calcium (CAC) as an initial diagnostic tool to rule out obstructive coronary artery disease (CAD) in a very large registry of patients presenting to the emergency department (ED) with acute chest pain (CP) who were at low to intermediate risk for acute coronary syndrome (ACS).
Background
It is not yet well established whether CAC can be used to rule out obstructive CAD in the ED setting.
Methods
We included patients from the Baptist Health South Florida Chest Pain Registry presenting to the ED with CP at low to intermediate risk for ACS (Thrombolysis In Myocardial Infarction risk score ≤2, normal/nondiagnostic electrocardiography, and troponin levels) who underwent CAC and coronary computed tomography angiography (CCTA) procedures for evaluation of ACS. To assess the diagnostic accuracy of CAC testing to diagnose obstructive CAD and identify the need for coronary revascularization during hospitalization, we estimated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV).
Results
Our study included 5,192 patients (mean age: 53.5 ± 10.8 years; 46% male; 62% Hispanic). Overall, 2,902 patients (56%) had CAC = 0, of which 135 (4.6%) had CAD (114 [3.9%] nonobstructive and 21 [0.7%] obstructive). Among those with CAC >0, 23% had obstructive CAD. Sensitivity, specificity, PPV, and NPV of CAC testing to diagnose obstructive CAD were 96.2%, 62.4%, 22.4%, and 99.3%, respectively. The NPV for identifying those who needed revascularization was 99.6%. Among patients with CAC = 0, 11 patients (0.4%) underwent revascularization, and the number needed to test with CCTA to detect 1 patient who required revascularization was 264.
Conclusions
In a large population presenting to ED with CP at low to intermediate risk, CAC = 0 was common. CAC = 0 ruled out obstructive CAD and revascularization in more than 99% of the patients, and <5% with CAC = 0 had any CAD. Integrating CAC testing very early in CP evaluation may be effective in appropriate triage of patients by identifying individuals who can safely defer additional testing and more invasive procedures.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print
Grandhi GR, Mszar R, Cainzos-Achirica M, Rajan T, ... Cury RC, Nasir K
JACC Cardiovasc Imaging: 06 Oct 2021; epub ahead of print | PMID: 34656462
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

CMR in Evaluating Valvular Heart Disease: Diagnosis, Severity, and Outcomes.

Myerson SG
Cardiac magnetic resonance (CMR) is a versatile imaging tool that brings much to the assessment of valvular heart disease. Although it is best known for myocardial imaging (even in valve disease), it provides excellent assessment of all 4 heart valves, with some distinct advantages, including a free choice of image planes and accurate flow and volumetric quantification. These allow the severity of each valve lesion to be characterized, in addition to optimal visualization of the surrounding outflow tracts and vessels, to deliver a comprehensive package. It can assess each valve lesion separately (in multiple valve disease) and is not affected by hemodynamic status. The accurate quantitation of regurgitant lesions and the ability to characterize myocardial changes also provides an ability to predict future clinical outcomes in asymptomatic patients. This review outlines how CMR can be used in cardiac valve disease to compliment echocardiography and enhance the patient assessment. It covers the main CMR methods used, their strengths and limitations, and the optimal way to apply them to evaluate valve disease.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2021; 14:2020-2032
Myerson SG
JACC Cardiovasc Imaging: 29 Sep 2021; 14:2020-2032 | PMID: 33248967
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Pre-Treatment Myocardial FDG Uptake Predicts Response to Immunosuppression in Patients With Cardiac Sarcoidosis.

Subramanian M, Swapna N, Ali AZ, Saggu DK, ... Swamy LTN, Narasimhan C
Objectives
This study identified predictors of clinical (CR) and echocardiographic response (ER) following immunosuppressive therapy (IST) in patients with cardiac sarcoidosis (CS).
Background
IST has been the cornerstone of treatment for patients with CS and active myocardial inflammation. However, there are little data to explain the variable response to IST in CS.
Methods
Data of 96 consecutive patients with CS from the Granulomatous Myocarditis Registry were analyzed. All patients underwent a 18fluorodeoxy glucose positron emission tomography-computed tomography (18FDG-PET-CT) before initiation of IST. Response was assessed after 4 to 6 months of therapy. CR was defined as an improvement in functional class (New York Heart Association functional class ≥I) and freedom from ventricular arrhythmias and heart failure hospitalizations. ER was defined as an improvement in left ventricular ejection fraction (LVEF) ≥10%. ER was assessed only in patients with a LVEF <50%. Complete responders had no residual myocardial FDG uptake and fulfilled both response criteria. Partial responders fulfilled only 1 response criteria or had residual FDG uptake. Nonresponders did not fulfill either CR or ER criteria. The uptake index (UI) was defined as the product of maximum standardized uptake value and the number of LV segments with abnormal uptake on 18FDG-PET-CT.
Results
Among 91 patients included in the final analysis, 54.9%, 20.9%, and 24.2% of patients were classified as complete and partial responders and nonresponders, respectively. Cox regression analysis (all responders vs. nonresponders) identified the following as independent predictors of response following immunosuppression: LVEF >40% (hazard ratio: 1.61; 95% confidence interval: 1.06 to 7.69; p = 0.031) and myocardial UI >30 (hazard ratio: 1.28; 95% confidence interval: 1.05 to 6.12; p = 0.010). The final model had a good discriminative power (area under the curve [AUC]: 0.85) and predictive accuracy (sensitivity: 85.5%; specificity: 86.4%). Pre-treatment myocardial UI had a strong positive correlation with change in LVEF following immunosuppression.
Conclusions
Pre-treatment 18FDG myocardial uptake was a predictor of CR and ER response to immunosuppression in patients with CS.

Copyright © 2021. Published by Elsevier Inc.

JACC Cardiovasc Imaging: 29 Sep 2021; 14:2008-2016
Subramanian M, Swapna N, Ali AZ, Saggu DK, ... Swamy LTN, Narasimhan C
JACC Cardiovasc Imaging: 29 Sep 2021; 14:2008-2016 | PMID: 33454258
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Coronary Microvascular Dysfunction Assessed by Pressure Wire and CMR After STEMI Predicts Long-Term Outcomes.

Scarsini R, Shanmuganathan M, De Maria GL, Borlotti A, ... Banning AP, OxAMI Study Investigators
Objectives
This study sought to evaluate the long-term prognostic implications of coronary microvascular dysfunction (CMD) when assessed with both cardiovascular magnetic resonance (CMR) and index of microcirculatory resistance (IMR) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).
Background
Post-ischemic CMD can be assessed using the pressure-wire based IMR and/or by the presence of microvascular obstruction (MVO) on CMR.
Methods
A total of 198 patients with STEMI underwent IMR and MVO assessment. Patients were classified as follows: Group 1, no significant CMD (low IMR [≤40 U] and no MVO); Group 2, CMD with either high IMR (>40 U) or MVO; Group 3, CMD with both IMR >40 U and MVO. The primary endpoint was the composite of all-cause mortality, diagnosis of new heart failure, cardiac arrest, sustained ventricular tachycardia/fibrillation, and cardioverter defibrillator implantation.
Results
CMD with both high IMR and MVO was present in 23.7% of the cases (Group 3) and CMD with either high IMR or MVO was observed in 40.9% of cases (Group 2). At a median follow-up of 40.1 months, the primary endpoint occurred in 34 (17%) cases. At 1 year of follow-up, Group 3 (hazard ratio [HR]: 12.6; 95% confidence interval [CI]: 1.6 to 100.6; p = 0.017) but not Group 2 (HR: 7.2; 95% CI: 0.9 to 57.9; p = 0.062) had worse clinical outcomes compared with those with no significant CMD in Group 1. However, in the long-term, patients in Group 2 (HR: 4.2; 95% CI: 1.4 to 12.5; p = 0.009) and those in Group 3 (HR: 5.2; 95% CI: 1.7 to 16.2; p = 0.004) showed similar adverse outcomes, mainly driven by the occurrence of heart failure.
Conclusions
Post-ischemic CMD predicts a more than 4-fold increase in long-term risk of adverse outcomes, mainly driven by the occurrence of heart failure. Defining CMD by either invasive IMR >40 U or by CMR-assessed MVO showed similar risk of adverse outcomes.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2021; 14:1948-1959
Scarsini R, Shanmuganathan M, De Maria GL, Borlotti A, ... Banning AP, OxAMI Study Investigators
JACC Cardiovasc Imaging: 29 Sep 2021; 14:1948-1959 | PMID: 33865789
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Hyperventilation/Breath-Hold Maneuver to Detect Myocardial Ischemia by Strain-Encoded CMR: Diagnostic Accuracy of a Needle-Free Stress Protocol.

Ochs MM, Kajzar I, Salatzki J, Ochs AT, ... Katus HA, Friedrich MG
Objectives
The purpose of this study was to evaluate the diagnostic accuracy of a fast, needle-free test for myocardial ischemia using fast Strain-ENCoded (fSENC) cardiovascular MR (CMR) after a hyperventilation/breath-hold maneuver (HVBH).
Background
Myocardial stress testing is one of the most frequent diagnostic tests performed. Recent data indicate that CMR first-pass perfusion outperforms other modalities. Its use, however, is limited by the need for both, a vasodilatory stress and the intravenous application of gadolinium. Both are associated with added cost, safety concerns, and patient inconvenience. The combination of 2 novel CMR approaches, fSENC, an ultrafast technique to visualize myocardial strain, and HVBH, a physiological vasodilator, may overcome these limitations.
Methods
Patients referred for CMR stress testing underwent an extended protocol to evaluate 3 different tests: 1) adenosine-perfusion; 2) adenosine-strain; and 3) HVBH-strain. Diagnostic accuracy was assessed using quantitative coronary angiography as reference.
Results
A total of 122 patients (age 66 ± 11years; 80% men) suspected of obstructive coronary artery disease were enrolled. All participants completed the protocol without significant adverse events. Adenosine-strain and HVBH-strain provided significantly better diagnostic accuracy than adenosine-perfusion, both on a patient level (adenosine-strain: sensitivity 82%, specificity 83%; HVBH-strain: sensitivity 81%, specificity 86% vs. adenosine-perfusion: sensitivity 67%, specificity 92%; p < 0.05) and territory level (adenosine-strain: sensitivity 67%, specificity 93%; HVBH-strain: sensitivity 63%, specificity 95% vs. adenosine-perfusion: sensitivity 49%, specificity 96%; p < 0.05). However, these differences in diagnostic accuracy disappear by excluding patients with history of coronary artery bypass graft or previous myocardial infarction. The response of longitudinal strain differs significantly between ischemic and nonischemic segments to adenosine (ΔLSischemic = 0.6 ± 5.4%, ΔLSnonischemic = -0.9 ± 2.7%; p < 0.05) and HVBH (ΔLSischemic = 1.3% ± 3.8%, ΔLSnonischemic = -0.3 ± 1.8%; p = 0.002). Test duration of HVBH-strain (t = 64 ± 2 s) was significantly shorter compared with adenosine-strain (t = 184 ± 59 s; p < 0.0001) and adenosine-perfusion (t = adenosine-perfusion: 172 ± 59 s; p < 0.0001).
Conclusions
HVBH-strain has a high diagnostic accuracy in detecting significant coronary artery stenosis. It is not only significantly faster than any other method but also neither requires contrast agents nor pharmacological stressors.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2021; 14:1932-1944
Ochs MM, Kajzar I, Salatzki J, Ochs AT, ... Katus HA, Friedrich MG
JACC Cardiovasc Imaging: 29 Sep 2021; 14:1932-1944 | PMID: 33865775
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Mechanisms Underlying the Association of Chronic Obstructive Pulmonary Disease With Heart Failure.

Lagan J, Schelbert EB, Naish JH, Vestbo J, ... Schmitt M, Miller CA
Objectives
The purposes of this study were to determine why chronic obstructive pulmonary disease (COPD) is associated with heart failure (HF). Specific objectives included whether COPD is associated with myocardial fibrosis, whether myocardial fibrosis is associated with hospitalization for HF and death in COPD, and whether COPD and smoking are associated with myocardial inflammation.
Background
COPD is associated with HF independent of shared risk factors. The underlying pathophysiological mechanism is unknown.
Methods
A prospective, multicenter, longitudinal cohort study of 572 patients undergoing cardiac magnetic resonance (CMR), including 450 patients with COPD and 122 age- and sex-matched patients with a median: 726 days (interquartile range: 492 to 1,160 days) follow-up. Multivariate analysis was used to examine the relationship between COPD and myocardial fibrosis, measured using cardiac magnetic resonance (CMR). Cox regression analysis was used to examine the relationship between myocardial fibrosis and outcomes; the primary endpoint was composite of hospitalizations for HF or all-cause mortality; secondary endpoints included hospitalizations for HF and all-cause mortality. Fifteen patients with COPD, 15 current smokers, and 15 healthy volunteers underwent evaluation for myocardial inflammation, including ultrasmall superparamagnetic particles of iron oxide CMR.
Results
COPD was independently associated with myocardial fibrosis (p < 0.001). Myocardial fibrosis was independently associated with the primary outcome (hazard ratio [HR]: 1.14; 95% confidence interval [CI]: 1.08 to 1.20; p < 0.001), hospitalization for HF (HR: 1.25 [95% CI: 1.14 to 1.36]); p < 0.001), and all-cause mortality. Myocardial fibrosis was associated with outcome measurements more strongly than any other variable. Acute and stable COPD were associated with myocardial inflammation.
Conclusions
The associations between COPD, myocardial inflammation and myocardial fibrosis, and the independent prognostic value of myocardial fibrosis elucidate a potential pathophysiological link between COPD and HF.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2021; 14:1963-1973
Lagan J, Schelbert EB, Naish JH, Vestbo J, ... Schmitt M, Miller CA
JACC Cardiovasc Imaging: 29 Sep 2021; 14:1963-1973 | PMID: 34023272
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

High-Risk Morphological and Physiological Coronary Disease Attributes as Outcome Markers After Medical Treatment and Revascularization.

Yang S, Koo BK, Hwang D, Zhang J, ... Kakuta T, Narula J
Objectives
This study sought to evaluate the prognostic impact of plaque morphology and coronary physiology on outcomes after medical treatment or percutaneous coronary intervention (PCI).
Background
Although fractional flow reserve (FFR) is currently best practice, morphological characteristics of coronary artery disease also contribute to outcomes.
Methods
A total of 872 vessels in 538 patients were evaluated by invasive FFR and coronary computed tomography angiography. High-risk attributes (HRA) were defined as high-risk physiological attribute (invasive FFR ≤0.8) and high-risk morphological attributes including: 1) local plaque burden (minimum lumen area <4 mm2 and plaque burden ≥70%); 2) adverse plaque characteristics ≥2; and 3) global plaque burden (total plaque volume ≥306.5 mm3 and percent atheroma volume ≥32.2%). The primary outcome was the composite of revascularization, myocardial infarction, or cardiac death at 5 years.
Results
The mean FFR was 0.88 ± 0.08, and PCI was performed in 239 vessels. The primary outcome occurred in 54 vessels (6.2%). All high-risk morphological attributes were associated with the increased risk of adverse outcomes after adjustment for FFR ≤0.8 and demonstrated direct prognostic effect not mediated by FFR ≤0.8. The 5-year event risk proportionally increased as the number of HRA increased (p for trend <0.001) with lower risk in the PCI group than the medical treatment group in vessels with 1 or 2 HRA (9.7% vs. 14.7%), but not in vessels with either 0 or ≥3 HRA. Of the vessels with pre-procedural FFR ≤0.8, ischemia relief by PCI (pre-PCI FFR ≤0.8 and post-PCI FFR >0.8) significantly reduced vessel-oriented composite outcome risk compared with medical treatment alone in vessels with 0 or 1 high-risk morphological attributes (hazard ratio: 0.33; 95% confidence interval: 0.12 to 0.93; p = 0.035), but the risk reduction was attenuated in vessels with ≥2 high-risk morphological attributes.
Conclusions
High-risk morphological attributes offered additive prognostic value to coronary physiology and may optimize selection of treatment strategies by adding to FFR-based risk predictions (CCTA-FFR Registry for Development of Comprehensive Risk Prediction Model; NCT04037163).

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2021; 14:1977-1989
Yang S, Koo BK, Hwang D, Zhang J, ... Kakuta T, Narula J
JACC Cardiovasc Imaging: 29 Sep 2021; 14:1977-1989 | PMID: 34023270
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Deep-Learning Models for the Echocardiographic Assessment of Diastolic Dysfunction.

Pandey A, Kagiyama N, Yanamala N, Segar MW, ... Tokodi M, Sengupta PP
Objectives
The authors explored a deep neural network (DeepNN) model that integrates multidimensional echocardiographic data to identify distinct patient subgroups with heart failure with preserved ejection fraction (HFpEF).
Background
The clinical algorithms for phenotyping the severity of diastolic dysfunction in HFpEF remain imprecise.
Methods
The authors developed a DeepNN model to predict high- and low-risk phenogroups in a derivation cohort (n = 1,242). Model performance was first validated in 2 external cohorts to identify elevated left ventricular filling pressure (n = 84) and assess its prognostic value (n = 219) in patients with varying degrees of systolic and diastolic dysfunction. In 3 National Heart, Lung, and Blood Institute-funded HFpEF trials, the clinical significance of the model was further validated by assessing the relationships of the phenogroups with adverse clinical outcomes (TOPCAT [Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function] trial, n = 518), cardiac biomarkers, and exercise parameters (NEAT-HFpEF [Nitrate\'s Effect on Activity Tolerance in Heart Failure With Preserved Ejection Fraction] and RELAX-HF [Evaluating the Effectiveness of Sildenafil at Improving Health Outcomes and Exercise Ability in People With Diastolic Heart Failure] pooled cohort, n = 346).
Results
The DeepNN model showed higher area under the receiver-operating characteristic curve than 2016 American Society of Echocardiography guideline grades for predicting elevated left ventricular filling pressure (0.88 vs. 0.67; p = 0.01). The high-risk (vs. low-risk) phenogroup showed higher rates of heart failure hospitalization and/or death, even after adjusting for global left ventricular and atrial longitudinal strain (hazard ratio [HR]: 3.96; 95% confidence interval [CI]: 1.24 to 12.67; p = 0.021). Similarly, in the TOPCAT cohort, the high-risk (vs. low-risk) phenogroup showed higher rates of heart failure hospitalization or cardiac death (HR: 1.92; 95% CI: 1.16 to 3.22; p = 0.01) and higher event-free survival with spironolactone therapy (HR: 0.65; 95% CI: 0.46 to 0.90; p = 0.01). In the pooled RELAX-HF/NEAT-HFpEF cohort, the high-risk (vs. low-risk) phenogroup had a higher burden of chronic myocardial injury (p < 0.001), neurohormonal activation (p < 0.001), and lower exercise capacity (p = 0.001).
Conclusions
This publicly available DeepNN classifier can characterize the severity of diastolic dysfunction and identify a specific subgroup of patients with HFpEF who have elevated left ventricular filling pressures, biomarkers of myocardial injury and stress, and adverse events and those who are more likely to respond to spironolactone.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2021; 14:1887-1900
Pandey A, Kagiyama N, Yanamala N, Segar MW, ... Tokodi M, Sengupta PP
JACC Cardiovasc Imaging: 29 Sep 2021; 14:1887-1900 | PMID: 34023263
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Machine Learning of ECG Waveforms to Improve Selection for Testing for Asymptomatic Left Ventricular Dysfunction.

Potter EL, Rodrigues CHM, Ascher DB, Abhayaratna WP, Sengupta PP, Marwick TH
Objectives
The purpose of this study was to identify whether machine learning from processing of continuous wave transforms (CWTs) to provide an \"energy waveform\" electrocardiogram (ewECG) could be integrated with echocardiographic assessment of subclinical systolic and diastolic left ventricular dysfunction (LVD).
Background
Asymptomatic LVD has management implications, but routine echocardiography is not undertaken in subjects at risk of heart failure. Signal processing of the surface ECG with the use of CWT can identify abnormal myocardial relaxation.
Methods
EwECG and echocardiography were undertaken in 398 participants at risk of heart failure (HF). Reduced global longitudinal strain (GLS ≤16%)), diastolic abnormalities (E/e\' >15, left atrial enlargement with E/e\' >10 or impaired relaxation) or LV hypertrophy defined LVD. EwECG feature selection and supervised machine-learning by random forest (RF) classifier was undertaken with 643 CWT-derived features and the ARIC (Atherosclerosis Risk In Communities) heart failure risk score.
Results
The ARIC score and 18 CWT features were selected to build a RF predictive model for LVD in a training dataset (n = 287; 60% female, median age 71 [interquartile range: 68 to 74] years). Model performance was tested in an independent group (n = 111; 49% female, median age 61 years [59 to 66 years]), demonstrating 85% sensitivity and 72% specificity (area under the receiver-operating characteristic curve [AUC]: 0.83; 95% confidence interval [CI]: 0.74 to 0.92). With ARIC score removed, sensitivity was 88% and specificity, 70% (AUC: 0.78; 95% CI: 0.70 to 0.86). RF models for reduced GLS and diastolic abnormalities including similar features had sensitivities that were unsuitable for screening. Conventional candidates for LVD screening (ARIC score, N-terminal pro-B-type natriuretic peptide, and standard automated ECG analysis) had inferior discriminative ability. Integration of ewECG in screening of people at risk of HF would reduce need for echocardiography by 45% while missing 12% of LVD cases.
Conclusions
Machine learning applied to ewECG is a sensitive screening test for LVD, and its integration into screening of patients at risk for HF would reduce the number of echocardiograms by almost one-half.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2021; 14:1904-1915
Potter EL, Rodrigues CHM, Ascher DB, Abhayaratna WP, Sengupta PP, Marwick TH
JACC Cardiovasc Imaging: 29 Sep 2021; 14:1904-1915 | PMID: 34147443
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Artificial Intelligence for Automatic Measurement of Left Ventricular Strain in Echocardiography.

Salte IM, Østvik A, Smistad E, Melichova D, ... Lovstakken L, Grenne B
Objectives
This study sought to examine if fully automated measurements of global longitudinal strain (GLS) using a novel motion estimation technology based on deep learning and artificial intelligence (AI) are feasible and comparable with a conventional speckle-tracking application.
Background
GLS is an important parameter when evaluating left ventricular function. However, analyses of GLS are time consuming and demand expertise, and thus are underused in clinical practice.
Methods
In this study, 200 patients with a wide range of left ventricle (LV) function were included. Three standard apical cine-loops were analyzed using the AI pipeline. The AI method measured GLS and was compared with a commercially available semiautomatic speckle-tracking software (EchoPAC v202, GE Healthcare.
Results
The AI method succeeded to both correctly classify all 3 standard apical views and perform timing of cardiac events in 89% of patients. Furthermore, the method successfully performed automatic segmentation, motion estimates, and measurements of GLS in all examinations, across different cardiac pathologies and throughout the spectrum of LV function. GLS was -12.0 ± 4.1% for the AI method and -13.5 ± 5.3% for the reference method. Bias was -1.4 ± 0.3% (95% limits of agreement: 2.3 to -5.1), which is comparable with intervendor studies. The AI method eliminated measurement variability and a complete GLS analysis was processed within 15 s.
Conclusions
Through the range of LV function this novel AI method succeeds, without any operator input, to automatically identify the 3 standard apical views, perform timing of cardiac events, trace the myocardium, perform motion estimation, and measure GLS. Fully automated measurements based on AI could facilitate the clinical implementation of GLS.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2021; 14:1918-1928
Salte IM, Østvik A, Smistad E, Melichova D, ... Lovstakken L, Grenne B
JACC Cardiovasc Imaging: 29 Sep 2021; 14:1918-1928 | PMID: 34147442
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Effect of Coronary CTA on Chronic Total Occlusion Percutaneous Coronary Intervention: A Randomized Trial.

Hong SJ, Kim BK, Cho I, Kim HY, ... Jang Y, CT-CTO Investigators
Objectives
The purpose of this study was to test whether the success rate of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) increased with pre-procedural coronary computed tomography angiography (CTA).
Background
Coronary CTA provides valuable information before and during CTO-PCI. However, there are no randomized data that explore whether coronary CTA increases its success rate.
Methods
In this multicenter, randomized trial, a total of 400 patients with CTO were randomized to receive PCI with pre-procedural coronary CTA (coronary CTA-guided group; n = 200) or without coronary CTA (angiography-guided group; n = 200) between January 2014 and September 2019. The primary endpoint was the successful recanalization rate, a final TIMI (Thrombolysis In Myocardial Infarction) grade ≥2, and ≤30% residual stenosis on the final angiogram.
Results
A total of 10 operators performed PCI. Successful recanalization was achieved in 187 patients (93.5%) in the coronary CTA-guided group and in 168 patients (84.0%) in the angiography-guided group (absolute difference, 9.5% [95% confidence interval: 3.4% to 15.6%]; p = 0.003). When comparing the success rates according to the Multicenter CTO Registry of Japan score (J-CTO), the coronary CTA guidance was favored over the angiography-guidance in the subset of J-CTO ≥2 versus in the subset of J-CTO <2 (p interaction = 0.035). Coronary perforations occurred in 2 (1%) and 8 patients (4%) in the coronary CTA- and angiography-guided groups, respectively (p = 0.055). Periprocedural myocardial infarction was not observed in the coronary CTA-guided group, whereas it occurred in 4 patients (2%) in the angiography-guided group (p = 0.123). Total procedure and fluoroscopic times were not different. There were no differences between the groups in the occurrences of cardiac death, target vessel-related myocardial infarction, or target-vessel revascularization at 1 year.
Conclusions
Pre-procedural coronary CTA-guidance for CTO resulted in higher success rates with numerically fewer immediate periprocedural complications such as coronary perforations or periprocedural myocardial infarction than angiography guidance. Higher success rates were more prominently observed in patients with CTO who had a high J-CTO score than those who did not. (Role of CT Scan for the Successful Recanalization of Chronic Total Occlusion; a Randomized Comparison Between 3D CT-guided PCI vs. Conventional Treatment [CT-CTO Trial]; NCT02037698).

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2021; 14:1993-2004
Hong SJ, Kim BK, Cho I, Kim HY, ... Jang Y, CT-CTO Investigators
JACC Cardiovasc Imaging: 29 Sep 2021; 14:1993-2004 | PMID: 34147439
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Diagnostic Value of F-Fluorodeoxyglucose Positron Emission Tomography Computed Tomography in Prosthetic Pulmonary Valve Infective Endocarditis.

Venet M, Jalal Z, Ly R, Malekzadeh-Milani S, ... Tlili G, Thambo JB
Objectives
The aim of this study was to assess the diagnostic performances of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) in congenital heart disease (CHD) patients with pulmonary prosthetic valve or conduit endocarditis (PPVE) suspicion.
Background
PPVE is a major issue in the growing CHD population. Diagnosis is challenging, and usual imaging tools are not always efficient or validated in this specific population. Particularly, the diagnostic yield of 18F-FDG PET/CT remains poorly studied in PPVE.
Methods
A retrospective multicenter study was conducted in 8 French tertiary centers. Children and adult CHD patients who underwent 18F-FDG PET/CT in the setting of PPVE suspicion between January 2010 and May 2020 were included. The cases were initially classified as definite, possible, or rejected PPVE regarding the modified Duke criteria and finally by the Endocarditis Team consensus. The result of 18F-FDG PET/CT had been compared with final diagnosis consensus used as gold-standard in our study.
Results
A total of 66 cases of PPVE suspicion involving 59 patients (median age 23 years, 73% men) were included. Sensitivity, specificity, positive predictive value, and negative predictive value of 18F-FDG PET/CT in PPVE suspicion were respectively: 79.1% (95% CI: 68.4%-91.4%), 72.7% (95% CI: 60.4%-85.0%), 91.9% (95% CI: 79.6%-100.0%), and 47.1% (95% CI: 34.8%-59.4%). 18F-FDG PET/CT findings would help to correctly reclassify 57% (4 of 7) of possible PPVE to definite PPVE.
Conclusions
Using 18F-FDG PET/CT improves the diagnostic accuracy of the Duke criteria in CHD patients with suspected PPVE. Its high positive predictive value could be helpful in routine to shorten diagnosis and treatment delays and improve clinical outcomes.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 07 Sep 2021; epub ahead of print
Venet M, Jalal Z, Ly R, Malekzadeh-Milani S, ... Tlili G, Thambo JB
JACC Cardiovasc Imaging: 07 Sep 2021; epub ahead of print | PMID: 34538632
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

T1 Mapping and Extracellular Volume Fraction in Dilated Cardiomyopathy: A Prognosis Study.

Li S, Zhou D, Sirajuddin A, He J, ... Arai AE, Lu M
Objectives
The aim of this study is to examine the prognostic value of T1 mapping and the extracellular volume (ECV) fraction in patients with dilated cardiomyopathy (DCM).
Background
Patients with DCM with functional left ventricular remodeling have poorer prognoses. Noninvasive assessment of myocardial fibrosis using T1 mapping and the ECV fraction may improve risk stratification of patients with DCM; however, this has not yet been systematically evaluated.
Methods
A total of 659 consecutive patients with DCM (498 men; 45 ± 15 years) who underwent cardiac magnetic resonance with T1 mapping and late gadolinium enhancement (LGE) imaging with a 1.5-T magnetic resonance scanner were enrolled in this study. Primary endpoints were cardiac-related death and heart transplantation. Secondary endpoints were hospitalization for heart failure, ventricular arrhythmias, and implantable cardioverter-defibrillator or cardiac resynchronization therapy implantation. Survival estimates were calculated by Kaplan-Meier curves with the log-rank test.
Results
During a mean follow-up of 66.3 ± 20.9 months, 122 and 205 patients with DCM reached the primary and secondary endpoints, respectively. The presence of LGE had an association with both of the primary and secondary endpoints observed in the patients with DCM (both P < 0.001). The maximum native T1 (HR: 1.04; 95% CI: 1.02-1.09) and maximum ECV fraction (HR: 1.14; 95% CI: 1.08-1.21) had associations with the primary endpoints in the patients with positive LGE (both P < 0.001), whereas the mean native T1 (HR: 1.13; 95% CI: 1.10-1.36) and mean ECV fraction (HR: 1.32; 95% CI: 1.12-1.53) had the best associations in the patients with negative LGE (all P < 0.001).
Conclusions
T1 mapping and the ECV fraction had prognostic value in patients with DCM and were particularly important in patients with DCM without LGE. Using a combination of T1 mapping, ECV fraction, and LGE provided optimal risk stratification for patients with DCM.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 07 Sep 2021; epub ahead of print
Li S, Zhou D, Sirajuddin A, He J, ... Arai AE, Lu M
JACC Cardiovasc Imaging: 07 Sep 2021; epub ahead of print | PMID: 34538631
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Dynamic Myocardial Perfusion CT for the Detection of Hemodynamically Significant Coronary Artery Disease.

Nous FMA, Geisler T, Kruk MBP, Alkadhi H, ... Bamberg F, Nieman K
Objectives
In this international, multicenter study, using third-generation dual-source computed tomography (CT), we investigated the diagnostic performance of dynamic stress CT myocardial perfusion imaging (CT-MPI) in addition to coronary CT angiography (CTA) compared to invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR).
Background
CT-MPI combined with coronary CTA integrates coronary artery anatomy with inducible myocardial ischemia, showing promising results for the diagnosis of hemodynamically significant coronary artery disease in single-center studies.
Methods
At 9 centers in Europe, Japan, and the United States, 132 patients scheduled for ICA were enrolled; 114 patients successfully completed coronary CTA, adenosine-stress dynamic CT-MPI, and ICA. Invasive FFR was performed in vessels with 25% to 90% stenosis. Data were analyzed by independent core laboratories. For the primary analysis, for each coronary artery the presence of hemodynamically significant obstruction was interpreted by coronary CTA with CT-MPI compared to coronary CTA alone, using an FFR of ≤0.80 and angiographic severity as reference. Territorial absolute myocardial blood flow (MBF) and relative MBF were compared using C-statistics.
Results
ICA and FFR identified hemodynamically significant stenoses in 74 of 289 coronary vessels (26%). Coronary CTA with ≥50% stenosis demonstrated a per-vessel sensitivity, specificity, and accuracy for the detection of hemodynamically significant stenosis of 96% (95% CI: 91-100), 72% (95% CI: 66-78), and 78% (95% CI: 73-83), respectively. Coronary CTA with CT-MPI showed a lower sensitivity (84%; 95% CI: 75-92) but higher specificity (89%; 95% CI: 85-93) and accuracy (88%; 95% CI: 84-92). The areas under the receiver-operating characteristic curve of absolute MBF and relative MBF were 0.79 (95% CI: 0.71-0.86) and 0.82 (95% CI: 0.74-0.88), respectively. The median dose-length product of CT-MPI and coronary CTA were 313 mGy·cm and 138 mGy·cm, respectively.
Conclusions
Dynamic CT-MPI offers incremental diagnostic value over coronary CTA alone for the identification of hemodynamically significant coronary artery disease. Generalized results from this multicenter study encourage broader consideration of dynamic CT-MPI in clinical practice. (Dynamic Stress Perfusion CT for Detection of Inducible Myocardial Ischemia [SPECIFIC]; NCT02810795).

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 07 Sep 2021; epub ahead of print
Nous FMA, Geisler T, Kruk MBP, Alkadhi H, ... Bamberg F, Nieman K
JACC Cardiovasc Imaging: 07 Sep 2021; epub ahead of print | PMID: 34538630
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Increased Vulnerability and Distinct Layered Phenotype at Culprit and Nonculprit Lesions in STEMI Versus NSTEMI.

Fang C, Yin Y, Jiang S, Zhang S, ... Dai J, Yu B
Objectives
This study aimed to investigate the pancoronary plaque vulnerability (including culprit and nonculprit lesions) and layered phenotype in patients with ST-segment elevation myocardial infarction (STEMI) vs non-STEMI (NSTEMI).
Background
Pancoronary vulnerability should account for distinct clinical manifestations of acute myocardial infarction (AMI). Layered plaque is indicative of previous coronary destabilization and thrombosis.
Methods
A total of 464 patients with AMI who underwent 3-vessel optical coherence tomography imaging were consecutively studied and divided into a STEMI group (318 patients; 318 culprit and 1,187 nonculprit plaques) and a NSTEMI group (146 patients; 146 culprit and 560 nonculprit plaques). Patients were followed up for a median period of 2 years.
Results
Compared with NSTEMI, culprit lesions in STEMI had more plaque rupture, thrombus, thin-cap fibroatheroma (TCFA), calcification, macrophage accumulation, and microvessels. The prevalence of plaque rupture (8.2% vs 4.8%; P = 0.018), microvessels (57.5% vs 45.2%; P < 0.001), and calcification (40.7% vs 30.2%; P = 0.003) at nonculprit lesions was higher in STEMI than NSTEMI. The layer area and thickness at the culprit and nonculprit lesions were significantly larger in STEMI than in NSTEMI. Multivariate analyses showed that culprit layer area (odds ratio: 1.443; 95% CI: 1.138-1.830; P = 0.002) was predictive of STEMI (vs NSTEMI), in addition to culprit TCFA, culprit thrombus, and non-left circumflex artery location of the culprit lesion. Although the type of AMI was not related to clinical outcomes, high-sensitivity C-reactive protein, culprit calcified nodule, and nonculprit TCFA predicted the 2-year major adverse cardiovascular events in patients with AMI.
Conclusions
Patients with STEMI had increased plaque vulnerability (ie, more plaque rupture and microvessels) and distinct layered phenotype at the culprit and nonculprit lesions compared with NSTEMI patients. Culprit lesion features of large layer area, TCFA, thrombus, and non-left circumflex artery location predicted the clinical presentation of STEMI.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 07 Sep 2021; epub ahead of print
Fang C, Yin Y, Jiang S, Zhang S, ... Dai J, Yu B
JACC Cardiovasc Imaging: 07 Sep 2021; epub ahead of print | PMID: 34538628
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Machine Learning-Derived Echocardiographic Phenotypes Predict Heart Failure Incidence in Asymptomatic Individuals.

Kobayashi M, Huttin O, Magnusson M, Ferreira JP, ... Girerd N, STANISLAS study
Objectives
This study sought to identify homogenous echocardiographic phenotypes in community-based cohorts and assess their association with outcomes.
Background
Asymptomatic cardiac dysfunction leads to a high risk of long-term cardiovascular morbidity and mortality; however, better echocardiographic classification of asymptomatic individuals remains a challenge.
Methods
Echocardiographic phenotypes were identified using K-means clustering in the first generation of the STANISLAS (Yearly non-invasive follow-up of Health status of Lorraine insured inhabitants) cohort (N = 827; mean age: 60 ± 5 years; men: 48%), and their associations with vascular function and circulating biomarkers were also assessed. These phenotypes were externally validated in the Malmö Preventive Project cohort (N = 1,394; mean age: 67 ± 6 years; men: 70%), and their associations with the composite of cardiovascular mortality (CVM) or heart failure hospitalization (HFH) were assessed as well.
Results
Three echocardiographic phenotypes were identified as \"mostly normal (MN)\" (n = 334), \"diastolic changes (D)\" (n = 323), and \"diastolic changes with structural remodeling (D/S)\" (n = 170). The D and D/S phenotypes had similar ages, body mass indices, cardiovascular risk factors, vascular impairments, and diastolic function changes. The D phenotype consisted mainly of women and featured increased levels of inflammatory biomarkers, whereas the D/S phenotype, consisted predominantly of men, displayed the highest values of left ventricular mass, volume, and remodeling biomarkers. The phenotypes were predicted based on a simple algorithm including e\', left ventricular mass and volume (e\'VM algorithm). In the Malmö cohort, subgroups derived from e\'VM algorithm were significantly associated with a higher risk of CVM and HFH (adjusted HR in the D phenotype = 1.87; 95% CI: 1.04 to 3.37; adjusted HR in the D/S phenotype = 3.02; 95% CI: 1.71 to 5.34).
Conclusions
Among asymptomatic, middle-aged individuals, echocardiographic data-driven classification based on the simple e\'VM algorithm identified profiles with different long-term HF risk. (4th Visit at 17 Years of Cohort STANISLAS-Stanislas Ancillary Study ESCIF [STANISLASV4]; NCT01391442).

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 07 Sep 2021; epub ahead of print
Kobayashi M, Huttin O, Magnusson M, Ferreira JP, ... Girerd N, STANISLAS study
JACC Cardiovasc Imaging: 07 Sep 2021; epub ahead of print | PMID: 34538625
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Label-Free Visualization and Quantification of Biochemical Markers of Atherosclerotic Plaque Progression Using Intravascular Fluorescence Lifetime.

Bec J, Vela D, Phipps JE, Agung M, ... Buja LM, Marcu L
Objectives
This study aimed to systematically investigate whether plaque autofluorescence properties assessed with intravascular fluorescence lifetime imaging (FLIm) can provide qualitative and quantitative information about intimal composition and improve the characterization of atherosclerosis lesions.
Background
Despite advances in cardiovascular diagnostics, the analytic tools and imaging technologies currently available have limited capabilities for evaluating in situ biochemical changes associated with luminal surface features. Earlier studies of small number of samples have shown differences among the autofluorescence lifetime signature of well-defined lesions, but a systematic pixel-level evaluation of fluorescence signatures associated with various histological features is lacking and needed to better understand the origins of fluorescence contrast.
Methods
Human coronary artery segments (n = 32) were analyzed with a bimodal catheter system combining multispectral FLIm with intravascular ultrasonography compatible with in vivo coronary imaging. Various histological components present along the luminal surface (200-μm depth) were systematically tabulated (12 sectors) from each serial histological section (n = 204). Morphological information provided by ultrasonography allowed for the accurate registration of imaging data with histology data. The relationships between histological findings and FLIm parameters obtained from 3 spectral channels at each measurement location (n = 33,980) were characterized.
Results
Our findings indicate that fluorescence lifetime from different spectral bands can be used to quantitatively predict the superficial presence of macrophage foam cells (mFCs) (area under the receiver-operator characteristic curve: 0.94) and extracellular lipid content in advanced lesions (lifetime increase in 540-nm band), detect superficial calcium (lifetime decrease in 450-nm band area under the receiver-operator characteristic curve: 0.90), and possibly detect lesions consistent with active plaque formation such as pathological intimal thickening and healed thrombus regions (lifetime increase in 390-nm band).
Conclusions
Our findings indicate that autofluorescence lifetime provides valuable information for characterizing atherosclerotic lesions in coronary arteries. Specifically, FLIm can be used to identify key phenomena linked with plaque progression (e.g., peroxidized-lipid-rich mFC accumulation and recent plaque formation).

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1832-1842
Bec J, Vela D, Phipps JE, Agung M, ... Buja LM, Marcu L
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1832-1842 | PMID: 33221238
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Implementing Coronary Computed Tomography Angiography in the Catheterization Laboratory.

Collet C, Sonck J, Leipsic J, Monizzi G, ... Andreini D, De Bruyne B
Coronary computed tomography angiography (CCTA) is now an established tool in the diagnostic work-up of patients suspected to have coronary artery disease. Yet, its usefulness beyond this phase has not been fully explored. The current review focuses on the implementation of CCTA as a tool to plan and guide coronary interventions in the catheterization laboratory. Specifically, we explore the potential of CCTA to improve patient selection for percutaneous revascularization, provide the rationale for better resource use, and present a novel approach to incorporate 3-dimensional CT guidance for percutaneous coronary interventions.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1846-1855
Collet C, Sonck J, Leipsic J, Monizzi G, ... Andreini D, De Bruyne B
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1846-1855 | PMID: 33248968
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Worldwide Variation in the Use of Nuclear Cardiology Camera Technology, Reconstruction Software, and Imaging Protocols.

Hirschfeld CB, Mercuri M, Pascual TNB, Karthikeyan G, ... Einstein AJ, INCAPS Investigators Group
Objectives
This study sought to describe worldwide variations in the use of myocardial perfusion imaging hardware, software, and imaging protocols and their impact on radiation effective dose (ED).
Background
Concerns about long-term effects of ionizing radiation have prompted efforts to identify strategies for dose optimization in myocardial perfusion scintigraphy. Studies have increasingly shown opportunities for dose reduction using newer technologies and optimized protocols.
Methods
Data were submitted voluntarily to the INCAPS (International Atomic Energy Agency Nuclear Cardiology Protocols Study) registry, a multinational, cross-sectional study comprising 7,911 imaging studies from 308 labs in 65 countries. The study compared regional use of camera technologies, advanced post-processing software, and protocol characteristics and analyzed the influence of each factor on ED.
Results
Cadmium-zinc-telluride and positron emission tomography (PET) cameras were used in 10% (regional range 0% to 26%) and 6% (regional range 0% to 17%) of studies worldwide. Attenuation correction was used in 26% of cases (range 10% to 57%), and advanced post-processing software was used in 38% of cases (range 26% to 64%). Stress-first single-photon emission computed tomography (SPECT) imaging comprised nearly 20% of cases from all world regions, except North America, where it was used in just 7% of cases. Factors associated with lower ED and odds ratio for achieving radiation dose ≤9 mSv included use of cadmium-zinc-telluride, PET, advanced post-processing software, and stress- or rest-only imaging. Overall, 39% of all studies (97% PET and 35% SPECT) were ≤9 mSv, while just 6% of all studies (32% PET and 4% SPECT) achieved a dose ≤3 mSv.
Conclusions
Newer-technology cameras, advanced software, and stress-only protocols were associated with reduced ED, but worldwide adoption of these practices was generally low and varied significantly between regions. The implementation of dose-optimizing technologies and protocols offers an opportunity to reduce patient radiation exposure across all world regions.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1819-1828
Hirschfeld CB, Mercuri M, Pascual TNB, Karthikeyan G, ... Einstein AJ, INCAPS Investigators Group
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1819-1828 | PMID: 33454257
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Myocardial Injury and Fibrosis From Acute Carbon Monoxide Poisoning: A Prospective Observational Study.

Cho DH, Ko SM, Son JW, Park EJ, Cha YS
Objectives
This study sought to evaluate the prevalence and patterns of late gadolinium enhancement (LGE) after carbon monoxide (CO) poisoning using cardiac magnetic resonance (CMR) imaging (CMRI) and transthoracic echocardiography (TTE).
Background
In acute CO poisoning, cardiac injury can predict mortality. However, it remains unclear why increased mortality and cardiovascular events occur despite normalization of CO-induced elevated troponin I (TnI) and cardiac dysfunction.
Methods
Patients with acute CO poisoning with elevated TnI were evaluated. CMRI was performed within 7 days of CO exposure and after 4 to 5 months. Patients were divided into LGE (n = 72; 69.2%) and no-LGE (n = 32; 30.8%) groups.
Results
In the LGE group, 39.4%, 4.8%, and 25.0% of patients exhibited midwall, subendocardial, and right ventricular insertion point injury, respectively. Diffuse injury was observed in 22.1% of patients, and 67.6% of the 37 patients who underwent follow-up CMRI showed no interval change. On TTE, baseline left ventricular ejection fraction and global longitudinal strain were significantly deteriorated in the LGE group; serial TTE within 7 days indicated that only left ventricular global longitudinal strain remained significantly deteriorated. Three cases of mortality occurred in the LGE group during the 1-year follow-up.
Conclusions
The LGE prevalence in patients with acute CO poisoning with elevated TnI levels, with no underlying cardiovascular diseases and eligible for CMRI, was 69.2%; this proportion primarily comprised patients with a midwall injury. Of the 37 patients who underwent follow-up CMRI, most chronic phase images showed no interval change. Myocardial fibrosis detected on CMR images was related to acute myocardial dysfunction and subacute deterioration of myocardial strain on TTE. (Cardiac Magnetic Resonance Image in Acute Carbon Monoxide Poisoning; NCT04419298).

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1758-1770
Cho DH, Ko SM, Son JW, Park EJ, Cha YS
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1758-1770 | PMID: 33865788
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Early Comprehensive Cardiovascular Magnetic Resonance Imaging in Patients With Myocardial Infarction With Nonobstructive Coronary Arteries.

Sörensson P, Ekenbäck C, Lundin M, Agewall S, ... Ugander M, Tornvall P
Objectives
The objective of the SMINC-2 (Stockholm Myocardial Infarction With Normal Coronaries 2) study was to determine if more than 70% of patients with myocardial infarction with nonobstructed coronary arteries (MINOCA), investigated early with comprehensive cardiovascular magnetic resonance (CMR), could receive a diagnosis entirely by imaging.
Background
The etiology of MINOCA is heterogeneous, including coronary, cardiac, and noncardiac causes. Patients with MINOCA, therefore, represent a diagnostic challenge where CMR is increasingly used.
Methods
The SMINC-2 study was a prospective study of 148 patients with MINOCA imaged with 1.5-T CMR with T1 and extracellular volume mapping early after hospital admission, compared to 150 patients with MINOCA imaged using 1.5-T CMR without mapping techniques from the SMINC-1 study as historic controls.
Results
CMR was performed at a median of 3 (SMINC-2) versus 12 (SMINC-1) days after hospital admission. In total, 77% of patients received a diagnosis with CMR imaging in the SMINC-2 study compared to 47% in the SMINC-1 study (p < 0.001). Compared to SMINC-1, CMR in SMINC-2 detected higher proportions of myocarditis (17% vs. 7%; p = 0.01) and takotsubo syndrome (35% vs. 19%; p = 0.002) but similar proportions of myocardial infarction (22% vs. 19%; p = 0.56) and other cardiomyopathies (3% vs. 2%; p = 0.46).
Conclusions
The results of the SMINC-2 study show that 77% of all patients with MINOCA received a diagnosis when imaged early with CMR, including advanced tissue characterization, which was a considerable improvement in comparison to the SMINC-1 study. This supports the use of early CMR imaging as a diagnostic tool in the investigation of patients with MINOCA. (Stockholm Myocardial Infarction With Normal Coronaries [SMINC]-2 Study on Diagnosis Made by Cardiac MRI [SCMINC-2]; NCT02318498).

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1774-1783
Sörensson P, Ekenbäck C, Lundin M, Agewall S, ... Ugander M, Tornvall P
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1774-1783 | PMID: 33865778
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

A Strain-Based Staging Classification of Left Bundle Branch Block-Induced Cardiac Remodeling.

Calle S, Kamoen V, De Buyzere M, De Pooter J, Timmermans F
Objectives
This study speculated that longitudinal strain curves in left bundle branch block (LBBB) could be shaped by the degree of LBBB-induced cardiac remodeling.
Background
LBBB independently affects left ventricular (LV) structure and function, but large individual variability may exist in LBBB-induced adverse remodeling.
Methods
Consecutive patients with LBBB with septal flash (LBBB-SF) underwent thorough echocardiographic assessment, including speckle tracking-based strain analysis. Four major septal longitudinal strain patterns (LBBB-1 through LBBB-4) were discerned and staged on the basis of: 1) correlation analysis with echocardiographic indexes of cardiac remodeling, including the extent of SF; 2) strain pattern analysis in cardiac resynchronization therapy (CRT) super-responders; and 3) strain pattern analysis in patients with acute procedural-induced LBBB.
Results
The study enrolled 237 patients with LBBB-SF (mean age: 67 ± 13 years; 57% men). LBBB-1 was observed in 60 (26%), LBBB-2 in 118 (50%), LBBB-3 in 29 (12%), and LBBB-4 in 26 (11%) patients. Patients at higher LBBB stages had larger end-diastolic volumes, lower LV ejection fractions, longer QRS duration, increased mechanical dyssynchrony, and more prominent SF compared with less advanced stages (p < 0.001 for all). Among CRT super-responders (n = 30; mean age: 63 ± 10 years), an inverse transition from stages LBBB-3 and -4 (pre-implant) to stages LBBB-1 and -2 (pace-off, median follow-up of 66 months [interquartile range: 32 to 78 months]) was observed (p < 0.001). Patients with acute LBBB (n = 27; mean age: 83 ± 5.1 years) only presented with a stage LBBB-1 (72%) or -2 pattern (24%).
Conclusions
The proposed classification suggests a pathophysiological continuum of LBBB-induced LV remodeling and may be valuable to assess the attribution of LBBB to the extent of LV remodeling and dysfunction.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1691-1702
Calle S, Kamoen V, De Buyzere M, De Pooter J, Timmermans F
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1691-1702 | PMID: 33865764
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Clinical Validation of a 3-Dimensional Ultrafast Cardiac Magnetic Resonance Protocol Including Single Breath-Hold 3-Dimensional Sequences.

Gómez-Talavera S, Fernandez-Jimenez R, Fuster V, Nothnagel ND, ... Ibáñez B, Sánchez-González J
Objectives
This study sought to clinically validate a novel 3-dimensional (3D) ultrafast cardiac magnetic resonance (CMR) protocol including cine (anatomy and function) and late gadolinium enhancement (LGE), each in a single breath-hold.
Background
CMR is the reference tool for cardiac imaging but is time-consuming.
Methods
A protocol comprising isotropic 3D cine (Enhanced sensitivity encoding [SENSE] by Static Outer volume Subtraction [ESSOS]) and isotropic 3D LGE sequences was compared with a standard cine+LGE protocol in a prospective study of 107 patients (age 58 ± 11 years; 24% female). Left ventricular (LV) mass, volumes, and LV and right ventricular (RV) ejection fraction (LVEF, RVEF) were assessed by 3D ESSOS and 2D cine CMR. LGE (% LV) was assessed using 3D and 2D sequences.
Results
Three-dimensional and LGE acquisitions lasted 24 and 22 s, respectively. Three-dimensional and LGE images were of good quality and allowed quantification in all cases. Mean LVEF by 3D and 2D CMR were 51 ± 12% and 52 ± 12%, respectively, with excellent intermethod agreement (intraclass correlation coefficient [ICC]: 0.96; 95% confidence interval [CI]: 0.94 to 0.97) and insignificant bias. Mean RVEF 3D and 2D CMR were 60.4 ± 5.4% and 59.7 ± 5.2%, respectively, with acceptable intermethod agreement (ICC: 0.73; 95% CI: 0.63 to 0.81) and insignificant bias. Both 2D and 3D LGE showed excellent agreement, and intraobserver and interobserver agreement were excellent for 3D LGE.
Conclusions
ESSOS single breath-hold 3D CMR allows accurate assessment of heart anatomy and function. Combining ESSOS with 3D LGE allows complete cardiac examination in <1 min of acquisition time. This protocol expands the indication for CMR, reduces costs, and increases patient comfort.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1742-1754
Gómez-Talavera S, Fernandez-Jimenez R, Fuster V, Nothnagel ND, ... Ibáñez B, Sánchez-González J
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1742-1754 | PMID: 33865783
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Sex-Specific Computed Tomography Coronary Plaque Characterization and Risk of Myocardial Infarction.

Williams MC, Kwiecinski J, Doris M, McElhinney P, ... Dweck MR, Dey D
Objectives
This study was designed to investigate whether coronary computed tomography angiography assessments of coronary plaque might explain differences in the prognosis of men and women presenting with chest pain.
Background
Important sex differences exist in coronary artery disease. Women presenting with chest pain have different risk factors, symptoms, prevalence of coronary artery disease and prognosis compared to men.
Methods
Within a multicenter randomized controlled trial, we explored sex differences in stenosis, adverse plaque characteristics (positive remodeling, low-attenuation plaque, spotty calcification, or napkin ring sign) and quantitative assessment of total, calcified, noncalcified and low-attenuation plaque burden.
Results
Of the 1,769 participants who underwent coronary computed tomography angiography, 772 (43%) were female. Women were more likely to have normal coronary arteries and less likely to have adverse plaque characteristics (p < 0.001 for all). They had lower total, calcified, noncalcified, and low-attenuation plaque burdens (p < 0.001 for all) and were less likely to have a low-attenuation plaque burden >4% (41% vs. 59%; p < 0.001). Over a median follow-up of 4.7 years, myocardial infarction (MI) occurred in 11 women (1.4%) and 30 men (3%). In those who had MI, women had similar total, noncalcified, and low-attenuation plaque burdens as men, but men had higher calcified plaque burden. Low-attenuation plaque burden predicted MI (hazard ratio: 1.60; 95% confidence interval: 1.10 to 2.34; p = 0.015), independent of calcium score, obstructive disease, cardiovascular risk score, and sex.
Conclusions
Women presenting with stable chest pain have less atherosclerotic plaque of all subtypes compared to men and a lower risk of subsequent MI. However, quantitative low-attenuation plaque is as strong a predictor of subsequent MI in women as in men. (Scottish Computed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590).

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1804-1814
Williams MC, Kwiecinski J, Doris M, McElhinney P, ... Dweck MR, Dey D
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1804-1814 | PMID: 33865779
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

A Machine-Learning Framework to Identify Distinct Phenotypes of Aortic Stenosis Severity.

Sengupta PP, Shrestha S, Kagiyama N, Hamirani Y, ... Dweck MR, Artificial Intelligence for Aortic Stenosis at Risk International Consortium
Objectives
The authors explored the development and validation of machine-learning models for augmenting the echocardiographic grading of aortic stenosis (AS) severity.
Background
In AS, symptoms and adverse events develop secondarily to valvular obstruction and left ventricular decompensation. The current echocardiographic grading of AS severity focuses on the valve and is limited by diagnostic uncertainty.
Methods
Using echocardiography (ECHO) measurements (ECHO cohort, n = 1,052), we performed patient similarity analysis to derive high-severity and low-severity phenogroups of AS. We subsequently developed a supervised machine-learning classifier and validated its performance with independent markers of disease severity obtained using computed tomography (CT) (CT cohort, n = 752) and cardiovascular magnetic resonance (CMR) imaging (CMR cohort, n = 160). The classifier\'s prognostic value was further validated using clinical outcomes (aortic valve replacement [AVR] and death) observed in the ECHO and CMR cohorts.
Results
In 1,964 patients from the 3 multi-institutional cohorts, 1,346 (68%) subjects had either nonsevere or discordant AS severity. Machine learning identified 1,117 (57%) patients as having high-severity and 847 (43%) as having low-severity AS. High-severity patients in CT and CMR cohorts had higher valve calcium scores and left ventricular mass and fibrosis, respectively than the low-severity group. In the ECHO cohort, progression to AVR and progression to death in patients who did not receive AVR was faster in the high-severity group. Compared with the conventional classification of disease severity, machine-learning-based severity classification improved discrimination (integrated discrimination improvement: 0.07; 95% confidence interval: 0.02 to 0.12) and reclassification (net reclassification improvement: 0.17; 95% confidence interval: 0.11 to 0.23) for the outcome of AVR at 5 years. For both ECHO and CMR cohorts, we observed prognostic value of the machine-learning classifications for subgroups with asymptomatic, nonsevere or discordant AS.
Conclusions
Machine learning can integrate ECHO measurements to augment the classification of disease severity in most patients with AS, with major potential to optimize the timing of AVR.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1707-1720
Sengupta PP, Shrestha S, Kagiyama N, Hamirani Y, ... Dweck MR, Artificial Intelligence for Aortic Stenosis at Risk International Consortium
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1707-1720 | PMID: 34023273
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prognostic Implications of Associated Cardiac Abnormalities Detected on Echocardiography in Patients With Moderate Aortic Stenosis.

Amanullah MR, Pio SM, Ng ACT, Sin KYK, ... Ewe SH, Bax JJ
Objectives
This study aimed to evaluate the prevalence and prognostic value of the extent of extra-aortic valvular cardiac abnormalities in a large multicenter registry of patients with moderate AS.
Background
The prognostic significance of a new classification system that incorporates the extent of cardiac injury (beyond the aortic valve) has been proposed in patients with severe aortic stenosis (AS). Whether this can be applied to patients with moderate AS is unclear.
Methods
Based on the echocardiographic findings at the time of diagnosis of moderate AS (aortic valve area between 1.0 and 1.5 cm2 and dimensionless velocity index ratio of ≥0.25), a total of 1,245 patients were included and analyzed retrospectively. They were recategorized into 5 groups according to the extent of extra-aortic valvular cardiac abnormalities: none (Group 0), involving the left ventricle (Group 1), the left atrial or mitral valve (Group 2), the pulmonary artery vasculature or tricuspid valve (Group 3), or the right ventricle (Group 4). Patients were followed for all-cause mortality and combined endpoint (all-cause mortality, stroke, heart failure, or myocardial infarction).
Results
The distribution of patients according to the proposed classification was 13.1%, 26.8%, 42.6%, 10.6%, and 6.9% in Groups 0, 1, 2, 3, and 4, respectively. During a median follow-up of 4.3 (2.4 to 6.9) years, 564 (45.3%) patients died. There was a significant higher mortality rates with increasing extent of extra-aortic valvular cardiac abnormalities (log-rank p < 0.001). On multivariable analysis, the presence of extra-aortic valvular cardiac abnormalities remained independently associated with all-cause mortality and combined outcome, adjusted for aortic valve replacement as a time-dependent covariable. In particular, Group 2 and above were independently associated with all-cause mortality.
Conclusions
In patients with moderate AS, the presence of extra-aortic valvular cardiac abnormalities is associated with poor outcome.

Copyright © 2021. Published by Elsevier Inc.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1724-1737
Amanullah MR, Pio SM, Ng ACT, Sin KYK, ... Ewe SH, Bax JJ
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1724-1737 | PMID: 34023268
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Long-Term Prognostic Value of Stress CMR in Patients With Heart Failure and Preserved Ejection Fraction.

Pezel T, Hovasse T, Sanguineti F, Kinnel M, ... Unterseeh T, Garot J
Objectives
The objectives of this study were to investigate the long-term prognostic value of inducible myocardial ischemia assessed by vasodilator stress cardiovascular magnetic resonance (CMR) in patients with HFpEF.
Background
Some studies suggest that ischemia could play a key role in HF in patients with preserved ejection fraction (HFpEF).
Methods
Between 2008 and 2019, consecutive patients prospectively referred for stress CMR with HFpEF as defined by current guidelines, without known coronary artery disease (CAD), were followed for the occurrence of major adverse cardiovascular events (MACE), as defined by cardiovascular mortality or nonfatal myocardial infarction (MI). Secondary composite outcomes included cardiovascular mortality or hospitalization for acute HF. Cox regression analysis was performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE) by CMR.
Results
Among the 1,203 patients with HFpEF (73 ± 13 years of age; 29% males) who underwent stress CMR and completed follow-up (6.9 years interquartile range [IQR]: 6.7 to 7.7 years]), 108 experienced a MACE (9%). Kaplan-Meier analysis showed inducible ischemia and LGE were significantly associated with MACE (HR: 6.63; 95% confidence interval [CI]: 4.54 to 9.69; and HR: 2.56; 95% CI: 1.60 to 4.09, respectively; both p < 0.001) and secondary outcomes (HR: 8.40; 95% CI: 6.31 to 11.20; p < 0.001; and HR: 1.87; 95% CI: 1.27 to 2.76, respectively; p = 0.002). In multivariate analysis, inducible ischemia and LGE were independent predictors of MACE (HR: 6.10; 95% CI: 4.14 to 9.00; p < 0.001 and HR: 1.62; 95% CI: 1.06 to 2.49; p = 0.039; respectively).
Conclusions
Stress CMR-inducible myocardial ischemia and LGE have accurate discriminative long-term prognostic value in HFpEF patients without known CAD to predict the occurrence of MACE.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 16 Aug 2021; epub ahead of print
Pezel T, Hovasse T, Sanguineti F, Kinnel M, ... Unterseeh T, Garot J
JACC Cardiovasc Imaging: 16 Aug 2021; epub ahead of print | PMID: 34419409
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Screening and Risk Stratification Strategy Reduced Decompression Sickness Occurrence in Divers With Patent Foramen Ovale.

Honěk J, Šrámek M, Honěk T, Tomek A, ... Brabec M, Veselka J
Objectives
This paper sought to evaluate the occurrence of decompression sickness (DCS) after the application of a patent foramen ovale (PFO) screening and risk stratification strategy.
Background
PFO is associated with an increased risk of DCS. Recently, transcatheter closure was reported to reduce DCS occurrence in divers with a high-grade shunt. However, to date, there are no data regarding the effectiveness of any PFO screening and risk stratification strategy for divers.
Methods
A total of 829 consecutive divers (35.4 ± 10.0 years, 81.5% men) were screened for PFO by means of transcranial color-coded sonography in the DIVE-PFO (Decompression Illness Prevention in Divers with a Patent Foramen Ovale) registry. Divers with a high-grade PFO were offered either catheter-based PFO closure (the closure group) or advised conservative diving (high grades). Divers with a low-grade shunt were advised conservative diving (low grades), whereas those with no PFO continued unrestricted diving (controls). A telephone follow-up was performed. To study the effect of the screening and risk stratification strategy, DCS occurrence before enrollment and during the follow-up was compared.
Results
Follow-up was available for 748 (90%) divers. Seven hundred and 2 divers continued diving and were included in the analysis (mean follow-up 6.5 ± 3.5 years). The DCS incidence decreased significantly in all groups, except the controls. During follow-up, there were no DCS events in the closure group; DCS incidence was similar to the controls in the low-grade group (HR: 3.965; 95% CI: 0.558-28.18; P = 0.169) but remained higher in the high-grade group (HR: 26.170; 95% CI: 5.797-118.16; P < 0.0001).
Conclusions
The screening and risk stratification strategy using transcranial color-coded sonography was associated with a decrease in DCS occurrence in divers with PFO. Catheter-based PFO closure was associated with a DCS occurrence similar to the controls; the conservative strategy had a similar effect in the low-grade group, but in the high-grade group the DCS incidence remained higher than in all other groups.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 11 Aug 2021; epub ahead of print
Honěk J, Šrámek M, Honěk T, Tomek A, ... Brabec M, Veselka J
JACC Cardiovasc Imaging: 11 Aug 2021; epub ahead of print | PMID: 34419390
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Accuracy of Cardiac Magnetic Resonance Imaging Diagnosis of Pediatric Cardiac Masses: A Multicenter Study.

Beroukhim RS, Ghelani S, Ashwath R, Balasubramanian S, ... Valsangiacomo E, Geva T
Objectives
The goals of this study were to: 1) evaluate the cardiac magnetic resonance (CMR) characteristics of pediatric cardiac masses from a large international cohort; 2) test the accuracy of previously developed CMR-based diagnostic criteria; and 3) expand diagnostic criteria using new information.
Background
After diagnosis of a cardiac mass, clinicians must weigh the benefits and risks of ascertaining a tissue diagnosis. Limited data are available on the accuracy of previously developed noninvasive pediatric CMR-based diagnostic criteria.
Methods
CMR studies (children 0-18 years of age) with confirmatory histological and/or genetic diagnosis were analyzed by 2 reviewers, without knowledge of prior diagnosis. Diagnostic accuracy was graded as: 1) single correct diagnosis; 2) correct diagnosis among a differential; or 3) incorrect diagnosis.
Results
Of 213 cases, 174 (82%) had diagnoses that were represented in the previously published diagnostic criteria. In 70% of 174 cases, both reviewers achieved a single correct diagnosis (94% of fibromas, 71% of rhabdomyomas, and 50% of myxomas). When ≤2 differential diagnoses were included, both reviewers reached a correct diagnosis in 86% of cases. Of 29 malignant tumors, both reviewers indicated malignancy as a single diagnosis in 52% of cases. Including ≤2 differential diagnoses, both reviewers indicated malignancy in 83% of cases. Of 6 CMR sequences examined, acquisition of first-pass perfusion and late gadolinium enhancement were independently associated with a higher likelihood of a single correct diagnosis.
Conclusions
CMR of cardiac masses in children leads to an accurate diagnosis in most cases. A comprehensive imaging protocol is associated with higher diagnostic accuracy.

Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print
Beroukhim RS, Ghelani S, Ashwath R, Balasubramanian S, ... Valsangiacomo E, Geva T
JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print | PMID: 34419404
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Association of Regional Wall Shear Stress and Progressive Ascending Aorta Dilation in Bicuspid Aortic Valve.

Soulat G, Scott MB, Allen BD, Avery R, ... Barker AJ, Markl M
Objectives
The aim of this study was to evaluate the role of wall shear stress (WSS) as a predictor of ascending aorta (AAo) growth at 5 years or greater follow-up.
Background
Aortic 4-dimensional flow cardiac magnetic resonance (CMR) can quantify regions exposed to high WSS, a known stimulus for arterial wall dysfunction. However, its association with longitudinal changes in aortic dilation in patients with bicuspid aortic valve (BAV) is unknown.
Methods
This retrospective study identified 72 patients with BAV (45 ± 12 years) who underwent CMR for surveillance of aortic dilation at baseline and ≥5 years of follow-up. Four-dimensional flow CMR analysis included the calculation of WSS heat maps to compare regional WSS in individual patients with population averages of healthy age- and sex-matched subjects (database of 136 controls). The relative areas of the AAo and aorta (in %) exposed to elevated WSS (outside the 95% CI of healthy population averages) were quantified.
Results
At a median follow-up duration of 6.0 years, the mean AAo growth rate was 0.24 ± 0.20 mm/y. The fraction of the AAo exposed to elevated WSS at baseline was increased for patients with higher growth rates (>0.24 mm/y, n = 32) compared with those with growth rates <0.24 mm/y (19.9% [interquartile range (IQR): 10.2-25.5] vs 5.7% [IQR: 1.5-21.3]; P = 0.008). Larger areas of elevated WSS in the AAo and entire aorta were associated with higher rates of AAo dilation >0.24 mm/y (odds ratio: 1.51; 95% CI: 1.05-2.17; P = 0.026 and odds ratio: 1.70; 95% CI: 1.01-3.15; P = 0.046, respectively).
Conclusions
The area of elevated AAo WSS as assessed by 4-dimensional flow CMR identified BAV patients with higher rates of aortic dilation and thus might determine which patients require closer follow-up.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print
Soulat G, Scott MB, Allen BD, Avery R, ... Barker AJ, Markl M
JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print | PMID: 34419402
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prognostic Value of Stress Cardiac Magnetic Resonance in Patients With Known Coronary Artery Disease.

Antiochos P, Ge Y, Heydari B, Steel K, ... Simonetti OP, Kwong RY
Objectives
This study sought to determine whether stress cardiac magnetic resonance (CMR) provides clinically relevant risk reclassification in patients with known coronary artery disease (CAD) in a multicenter setting in the United States.
Background
Despite improvements in medical therapy and coronary revascularization, patients with previous CAD account for a disproportionately large portion of CV events and pose a challenge for noninvasive stress testing.
Methods
From the Stress Perfusion Imaging in the United States (SPINS) registry, we identified consecutive patients with documented CAD who were referred to stress CMR for evaluation of myocardial ischemia. The primary outcome was nonfatal myocardial infarction (MI) or cardiovascular (CV) death. Major adverse CV events (MACE) included MI/CV death, hospitalization for heart failure or unstable angina, and late unplanned coronary artery bypass graft. The prognostic association and net reclassification improvement by ischemia for MI/CV death were determined.
Results
Out of 755 patients (age 64 ± 11 years, 64% male), we observed 97 MI/CV deaths and 210 MACE over a median follow-up of 5.3 years. Presence of ischemia demonstrated a significant association with MI/CV death (HR: 2.30; 95% CI: 1.54-3.44; P < 0.001) and MACE (HR: 2.24 ([95% CI: 1.69-2.95; P < 0.001). In a multivariate model adjusted for CV risk factors, ischemia maintained strong association with MI/CV death (HR: 1.84; 95% CI: 1.17-2.88; P = 0.008) and MACE (HR: 1.77; 95% CI: 1.31-2.40; P < 0.001) and reclassified 95% of patients at intermediate pretest risk (62% to low risk, 33% to high risk) with corresponding changes in the observed event rates of 1.4% and 5.3% per year for low and high post-test risk, respectively.
Conclusions
In a multicenter cohort of patients with known CAD, CMR-assessed ischemia was strongly associated with MI/CV death and reclassified patient risk beyond CV risk factors, especially in those considered to be at intermediate risk. Absence of ischemia was associated with a <2% annual rate of MI/CV death. (Stress CMR Perfusion Imaging in the United States [SPINS] Study; NCT03192891).

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print
Antiochos P, Ge Y, Heydari B, Steel K, ... Simonetti OP, Kwong RY
JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print | PMID: 34419400
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Clinical Importance of Left Atrial Infiltration in Cardiac Transthyretin Amyloidosis.

Bandera F, Martone R, Chacko L, Ganesananthan S, ... Gillmore JD, Fontana M
Objectives
The aim of this study was to characterize left atrial (LA) pathology in explanted hearts with transthyretin amyloid cardiomyopathy (ATTR-CM); LA mechanics using echocardiographic speckle-tracking in a large cohort of patients with ATTR-CM; and to study the association with mortality.
Background
The clinical significance of LA involvement in ATTR-CM is of great clinical interest.
Methods
Congo red staining and immunohistochemistry was performed to assess the presence, type, and extent of amyloid and associated changes in 5 explanted ATTR-CM atria. Echo speckle tracking was used to assess LA reservoir, conduit, contractile function, and stiffness in 906 patients with ATTR-CM (551 wild-type (wt)-ATTR-CM; 93 T60A-ATTR-CM; 241 V122I-ATTR-CM; 21 other).
Results
There was extensive ATTR amyloid infiltration in the 5 atria, with loss of normal architecture, vessels remodeling, capillary disruption, and subendocardial fibrosis. Echo speckle tracking in 906 patients with ATTR-CM demonstrated increased atrial stiffness (median [25th-75th quartile] 1.83 [1.15-2.92]) that remained independently associated with prognosis after adjusting for known predictors (lnLA stiff: HR: 1.23; 95% CI: 1.03-1.49; P = 0.029). There was substantial impairment of the 3 phasic functional atrial components (reservoir 8.86% [5.94%-12.97%]; conduit 6.5% [4.53%-9.28%]; contraction function 4.0% [2.29%-6.56%]). Atrial contraction was absent in 22.1% of patients whose electrocardiograms showed sinus rhythm (SR) \"atrial electromechanical dissociation\" (AEMD). AEMD was associated with poorer prognosis compared with patients with SR and effective mechanical contraction (P = 0.0018). AEMD conferred a similar prognosis to patients in atrial fibrillation.
Conclusions
The phenotype of ATTR-CM includes significant infiltration of the atrial walls, with progressive loss of atrial function and increased stiffness, which is a strong independent predictor of mortality. AEMD emerged as a distinctive phenotype identifying patients in SR with poor prognosis.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print
Bandera F, Martone R, Chacko L, Ganesananthan S, ... Gillmore JD, Fontana M
JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print | PMID: 34419399
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Association of Tube Voltage With Plaque Composition on Coronary CT Angiography: Results From Paradigm Registry.

Takagi H, Leipsic JA, Indraratna P, Gulsin G, ... Bax JJ, Chang HJ
Objectives
This study sought to investigate the impact of low tube voltage scanning heterogeneity of coronary luminal attenuation on plaque quantification and characterization with coronary computed tomography angiography (CCTA).
Background
The impact of low tube voltage and coronary luminal attenuation on quantitative coronary plaque remains uncertain.
Methods
A total of 1,236 consecutive patients (age: 60 ± 9 years; 41% female) who underwent serial CCTA at an interval of ≥2 years were included from an international registry. Patients with prior revascularization or nonanalyzable coronary CTAs were excluded. Total coronary plaque volume was assessed and subclassified based on specific Hounsfield unit (HU) threshold: necrotic core, fibrofatty plaque, and fibrous plaque and dense calcium. Luminal attenuation was measured in the aorta.
Results
With increasing luminal HU (<350, 350-500, and >500 HU), percent calcified plaque was increased (16%, 27%, and 40% in the median; P < 0.001), and fibrofatty plaque (26%, 13%, and 4%; P < 0.001) and necrotic core (1.6%, 0.3%, and 0.0%; P < 0.001) were decreased. Higher tube voltage scanning (80, 100, and 120 kV) resulted in decreasing luminal attenuation (689 ± 135, 497 ± 89, and 391 ± 73 HU; P < 0.001) and calcified plaque volume (59%, 34%, and 23%; P < 0.001) and increased fibrofatty plaque (3%, 9%, and 18%; P < 0.001) and necrotic core (0.2%, 0.1%, and 0.6%; P < 0.001). Mediation analysis showed that the impact of 100 kV on plaque composition, compared with 120 kV, was primarily caused by an indirect effect through blood pool attenuation. Tube voltage scanning of 80 kV maintained a direct effect on fibrofatty plaque and necrotic core in addition to an indirect effect through the luminal attenuation.
Conclusions
Low tube voltage usage affected plaque morphology, mainly through an increase in luminal HU with a resultant increase in calcified plaque and a reduction in fibrofatty and necrotic core. These findings should be considered as CCTA-based plaque measures are being used to guide medical management and, in particular, when being used as a measure of treatment response. (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging [PARADIGM]; NCT02803411).

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print
Takagi H, Leipsic JA, Indraratna P, Gulsin G, ... Bax JJ, Chang HJ
JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print | PMID: 34419398
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Role of Exercise Treadmill Testing in the Assessment of Coronary Microvascular Disease.

Lopez DM, Divakaran S, Gupta A, Bajaj NS, ... Blankstein R, Di Carli MF
Objectives
The authors aimed to study the sensitivity and specificity of exercise treadmill testing (ETT) in the diagnosis of coronary microvascular disease (CMD), as well as the prognostic implications of ETT results in patients with CMD.
Background
ETT is validated to evaluate for flow-limiting coronary artery disease (CAD), however, little is known about its use for evaluating CMD.
Methods
We retrospectively studied 249 consecutive patients between 2006 and 2016 who underwent ETT and positron emission tomography within 12 months. Patients with obstructive CAD or left ventricular systolic dysfunction were excluded. CMD was defined as a coronary flow reserve <2. Patients were followed for the occurrence of a first major adverse event (composite of death or hospitalization for myocardial infarction or heart failure).
Results
The sensitivity and specificity of a positive ETT to detect CMD were 34.7% (95% CI: 25.4%-45.0%) and 64.9% (95% CI: 56.7%-72.5%), respectively. The specificity of a positive ETT to detect CMD increased to 86.8% (95% CI: 80.3%-91.7%) when only classifying studies with ischemic electrocardiogram changes that lasted at least 1 minute into recovery as positive, although at a cost of lower sensitivity (15.3%; 95% CI: 8.8%-24.0%). Over a median follow-up of 6.9 years (interquartile range: 5.1 years-8.2 years), 30 (12.1%) patients met the composite endpoint, including 13 (13.3%) with CMD (n = 98). In patients with CMD, ETT result was not associated with the composite endpoint (P = 0.076).
Conclusions
Our data suggest limited sensitivity of ETT to detect CMD. However, a positive ETT with ischemic changes that persist at least 1 minute into recovery in the absence of obstructive CAD should raise suspicion for the presence of CMD given a high specificity. Further study is needed with larger patient sample sizes to assess the association between ETT results and outcomes in patients with CMD.

Copyright © 2021. Published by Elsevier Inc.

JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print
Lopez DM, Divakaran S, Gupta A, Bajaj NS, ... Blankstein R, Di Carli MF
JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print | PMID: 34419395
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Reverse Myocardial Remodeling Following Valve Repair in Patients With Chronic Severe Primary Degenerative Mitral Regurgitation.

Liu B, Neil DAH, Bhabra M, Patel R, ... Edwards NC, Steeds RP
Objectives
The aims of this study were to quantify preoperative myocardial fibrosis using late gadolinium enhancement (LGE), extracellular volume fraction (ECV%), and indexed extracellular volume (iECV) on cardiac magnetic resonance; determine whether this varies following surgery; and examine the impact on postoperative outcomes.
Background
Myocardial fibrosis complicates chronic severe primary mitral regurgitation and is associated with left ventricular dilatation and dysfunction. It is not known if this nonischemic fibrosis is reversible following surgery or if it affects ventricular remodeling and patient outcomes.
Methods
A multicenter prospective study was conducted among 104 subjects with primary mitral regurgitation undergoing mitral valve repair. Cardiac magnetic resonance and cardiopulmonary exercise stress testing were performed preoperatively and ≥6 months after surgery. Symptoms were assessed using the Minnesota Living With Heart Failure Questionnaire.
Results
Mitral valve repair was performed for Class 2a indications in 65 patients and Class 1 indications in 39 patients. Ninety-three patients were followed up at 8.8 months (interquartile range: 7.4 months-10.6 months). Following surgery, there were significant reductions in both ECV% (from 27.4% to 26.6%; P = 0.027) and iECV (from 17.9 to 15.4 mL/m2; P < 0.001), but the incidence of LGE was unchanged. Neither preoperative ECV% nor LGE affected postoperative function, but iECV predicted left ventricular end-systolic volume index (β = 1.04; 95% CI: 0.49 to 1.58; P < 0.001) and left ventricular ejection fraction (β = -0.61; 95% CI: -1.05 to -0.18; P = 0.006). Patients with above-median iECV of ≥17.6 mL/m2 had significantly larger postoperative values of left ventricular end-systolic volume index (30.5 ± 12.7 mL/m2 vs 23.9 ± 8.0 mL/m2; P = 0.003), an association that remained significant in subcohort analyses of patients in New York Heart Association functional class I.
Conclusions
Mitral valve surgery results in reductions in ECV% and iECV, which are surrogates of diffuse myocardial fibrosis, and preoperative iECV predicts the degree of postoperative remodeling irrespective of symptoms. (The Role of Myocardial Fibrosis in Degenerative Mitral Regurgitation; NCT02355418).

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print
Liu B, Neil DAH, Bhabra M, Patel R, ... Edwards NC, Steeds RP
JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print | PMID: 34419393
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Cardiac Magnetic Resonance Assessment of Response to Cardiac Resynchronization Therapy and Programming Strategies.

Gao X, Abdi M, Auger DA, Sun C, ... Salerno M, Bilchick KC
Objectives
The objective was to determine the feasibility and effectiveness of cardiac magnetic resonance (CMR) cine and strain imaging before and after cardiac resynchronization therapy (CRT) for assessment of response and the optimal resynchronization pacing strategy.
Background
CMR with cardiac implantable electronic devices can safely provide high-quality right ventricular/left ventricular (LV) ejection fraction (RVEF/LVEF) assessments and strain.
Methods
CMR with cine imaging, displacement encoding with stimulated echoes for the circumferential uniformity ratio estimate with singular value decomposition (CURE-SVD) dyssynchrony parameter, and scar assessment was performed before and after CRT. Whereas the pre-CRT scan constituted a single \"imaging set\" with complete volumetric, strain, and scar imaging, multiple imaging sets with complete strain and volumetric data were obtained during the post-CRT scan for biventricular pacing (BIVP), LV pacing (LVP), and asynchronous atrial pacing modes by reprogramming the device outside the scanner between imaging sets.
Results
100 CMRs with a total of 162 imaging sets were performed in 50 patients (median age 70 years [IQR: 50 years-86 years]; 48% female). Reduction in LV end-diastolic volumes (P = 0.002) independent of CRT pacing were more prominent than corresponding reductions in right ventricular end-diastolic volumes (P = 0.16). A clear dependence of the optimal CRT pacing mode (BIVP vs LVP) on the PR interval (P = 0.0006) was demonstrated. The LVEF and RVEF improved more with BIVP than LVP with PR intervals ≥240 milliseconds (P = 0.025 and P = 0.002, respectively); the optimal mode (BIVP vs LVP) was variable with PR intervals <240 milliseconds. A lower pre-CRT displacement encoding with stimulated echoes CURE-SVD was associated with greater improvements in the post-CRT CURE-SVD (r = -0.69; P < 0.001), LV end-systolic volume (r = -0.58; P < 0.001), and LVEF (r = -0.52; P < 0.001).
Conclusions
CMR evaluation with assessment of multiple pacing modes during a single scan after CRT is feasible and provides useful information for patient care with respect to response and the optimal pacing strategy.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print
Gao X, Abdi M, Auger DA, Sun C, ... Salerno M, Bilchick KC
JACC Cardiovasc Imaging: 10 Aug 2021; epub ahead of print | PMID: 34419391
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Predictors of Rapid Plaque Progression: An Optical Coherence Tomography Study.

Araki M, Yonetsu T, Kurihara O, Nakajima A, ... Kakuta T, Jang IK
Objectives
This study sought to identify morphological predictors of rapid plaque progression.
Background
Two patterns of plaque progression have been described: slow linear progression and rapid step-wise progression. The former pattern will cause stable angina when the narrowing reaches a critical threshold, whereas the latter pattern may lead to acute coronary syndromes or sudden cardiac death.
Methods
Patients who underwent optical coherence tomography (OCT) imaging during the index procedure and follow-up angiography with a minimum interval of 6 months were selected. Nonculprit lesions with a diameter stenosis of ≥30% on index angiography were assessed. Lesion progression was defined as a decrease of angiographic minimum lumen diameter ≥0.4 mm at follow-up (mean, 7.1 months). Baseline morphological characteristics of plaques with rapid progression were evaluated by OCT. In a subgroup with follow-up OCT imaging for plaques with rapid progression, morphological changes from baseline to follow-up were assessed.
Results
Among 517 lesions in 248 patients, 50 lesions showed rapid progression. These lesions had a significantly higher prevalence of lipid-rich plaque (76.0% vs. 50.5%, respectively), thin-cap fibroatheroma (TCFA) (20.0% vs. 5.8%, respectively), layered plaque (60.0% vs. 34.0%, respectively), macrophage accumulation (62.0% vs. 42.4%, respectively), microvessel (46.0% vs. 29.1%, respectively), plaque rupture (12.0% vs. 4.7%, respectively), and thrombus (6.0% vs. 1.1%, respectively) at baseline compared with those without rapid progression. Multivariate analysis identified lipid-rich plaque (odds ratio [OR]: 2.17; 95% confidence interval [CI]: 1.02 to 4.62; p = 0.045]), TCFA (OR: 5.85; 95% CI: 2.01 to 17.03; p = 0.001), and layered plaque (OR: 2.19; 95% CI: 1.03 to 4.17; p = 0.040) as predictors of subsequent rapid lesion progression. In a subgroup analysis for plaques with rapid progression, a new layer was detected in 25 of 41 plaques (61.0%) at follow-up.
Conclusions
Lipid-rich plaques, TCFA, and layered plaques were predictors of subsequent rapid plaque progression. A new layer, a signature of previous plaque disruption and healing, was detected in more than half of the lesions with rapid progression at follow-up. (Massachusetts General Hospital Optical Coherence Tomography Registry; NCT01110538).

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1628-1638
Araki M, Yonetsu T, Kurihara O, Nakajima A, ... Kakuta T, Jang IK
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1628-1638 | PMID: 33011121
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prognostic Value of Radiotracer-Based Perfusion Imaging in Critical Limb Ischemia Patients Undergoing Lower Extremity Revascularization.

Chou TH, Alvelo JL, Janse S, Papademetris X, ... Sinusas AJ, Stacy MR
Objectives
The purpose of this study was to evaluate the prognostic value of single-photon emission computed tomography (SPECT)/computed tomography (CT) imaging of angiosome foot perfusion for predicting amputation outcomes in patients with critical limb ischemia (CLI) and diabetes mellitus (DM).
Background
Radiotracer imaging can assess microvascular foot perfusion and identify regional perfusion abnormalities in patients with critical limb ischemia CLI and DM, but the relationship between perfusion response to revascularization and subsequent clinical outcomes has not been evaluated.
Methods
Patients with CLI, DM, and nonhealing foot ulcers (n = 25) were prospectively enrolled for SPECT/CT perfusion imaging of the feet before and after revascularization. CT images were used to segment angiosomes (i.e., 3-dimensional vascular territories) of the foot. Relative changes in radiotracer uptake after revascularization were evaluated within the ulcerated angiosome. Incidence of amputation was assessed at 3 and 12 months after revascularization.
Results
SPECT/CT detected a significantly lower microvascular perfusion response for patients who underwent amputation compared with those who remained amputation free at 3 (p = 0.01) and 12 (p = 0.01) months after revascularization. The cutoff percent change in perfusion for predicting amputation at 3 months was 7.55%, and 11.56% at 12 months. The area under the curve based on the amputation outcome was 0.799 at 3 months and 0.833 at 12 months. The probability of amputation-free survival was significantly higher at 3 (p = 0.002) and 12 months (p = 0.03) for high-perfusion responders than low-perfusion responders to revascularization.
Conclusions
SPECT/CT imaging detects regional perfusion responses to lower extremity revascularization and provides prognostic value in patients with CLI (Radiotracer-Based Perfusion Imaging of Patients With Peripheral Arterial Disease; NCT03622359).

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1614-1624
Chou TH, Alvelo JL, Janse S, Papademetris X, ... Sinusas AJ, Stacy MR
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1614-1624 | PMID: 33221224
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Computed Tomography-Derived 3D Modeling to Guide Sizing and Planning of Transcatheter Mitral Valve Interventions.

Ooms JF, Wang DD, Rajani R, Redwood S, ... O\'Neill W, Van Mieghem NM
A plethora of catheter-based strategies have been developed to treat mitral valve disease. Evolving 3-dimensional (3D) multidetector computed tomography (MDCT) technology can accurately reconstruct the mitral valve by means of 3-dimensional computational modeling (3DCM) to allow virtual implantation of catheter-based devices. 3D printing complements computational modeling and offers implanting physician teams the opportunity to evaluate devices in life-size replicas of patient-specific cardiac anatomy. MDCT-derived 3D computational and 3D-printed modeling provides unprecedented insights to facilitate hands-on procedural planning, device training, and retrospective procedural evaluation. This overview summarizes current concepts and provides insight into the application of MDCT-derived 3DCM and 3D printing for the planning of transcatheter mitral valve replacement and closure of paravalvular leaks. Additionally, future directions in the development of 3DCM will be discussed.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1644-1658
Ooms JF, Wang DD, Rajani R, Redwood S, ... O'Neill W, Van Mieghem NM
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1644-1658 | PMID: 33744155
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prognostic Utility of Echocardiographic Atrial and Ventricular Strain Imaging in Patients With Cardiac Amyloidosis.

Huntjens PR, Zhang KW, Soyama Y, Karmpalioti M, Lenihan DJ, Gorcsan J
Objectives
The prognostic value of echocardiographic atrial and ventricular strain imaging in patients with biopsy-proven cardiac amyloidosis was assessed.
Background
Although left ventricular global longitudinal strain (GLS) is known to be predictive of outcome, the additive prognostic value of left (LA), right atrial (RA), and right ventricular (RV) strain is unclear.
Methods
One hundred thirty-six patients with cardiac amyloidosis and available follow-up data were studied by endomyocardial biopsy, noncardiac biopsy with supportive cardiac imaging, or autopsy confirmation. One hundred nine patients (80%) had light-chain, 23 (17%) had transthyretin, and 4 (3%) had amyloid A type cardiac amyloidosis. GLS, RV free wall strain, peak longitudinal LA strain, and peak longitudinal RA strain were measured from apical views. Clinical and routine echocardiographic data were compared. All-cause mortality was followed (median 5 years).
Results
Strain data were feasible for GLS in 127 (93%), LA strain in 119 (88%), RA strain in 117 (86%), and RV strain in 102 (75%). Strain values from all 4 chambers were significantly associated with survival. Hazard ratio (HR) and 95% confidence interval (CI) for low median strain values were as follows: GLS, HR: 2.3; 95% CI: 1.3 to 3.8 (p < 0.01); LA strain, HR: 7.5; 95% CI: 3.8 to 14.7 (p < 0.001); RA strain, HR: 3.5; 95% CI: 2.0 to 6.2 (p < 0.001); and RV free wall strain, HR: 2.8; 95% CI: 1.5 to 5.1 (p < 0.001). Peak longitudinal LA strain and RV strain remained independently associated with survival in multivariable analysis. Peak LA strain had the strongest association with survival (p < 0.001), and LA strain combined with GLS and RV free wall strain had the highest prognostic value (p < 0.001).
Conclusions
Strain data from all 4 chambers had important prognostic associations with survival in patients with biopsy-confirmed cardiac amyloidosis. Peak longitudinal LA strain was particularly associated with prognosis. Atrial and ventricular strain have promise for clinical utility.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1508-1519
Huntjens PR, Zhang KW, Soyama Y, Karmpalioti M, Lenihan DJ, Gorcsan J
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1508-1519 | PMID: 33744146
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Tricuspid Annulus Disjunction: Novel Findings by Cardiac Magnetic Resonance in Patients With Mitral Annulus Disjunction.

Aabel EW, Chivulescu M, Dejgaard LA, Ribe M, ... Lie ØH, Haugaa KH
Objectives
This study aimed to assess whether patients with MAD also have disjunction of the tricuspid annulus.
Background
Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral annulus. Whether the disjunction extends to the right side of the heart is not known.
Methods
In a cohort of patients with MAD, we assessed the presence of tricuspid annulus disjunction (TAD) with the use of cardiac magnetic resonance. We explored the associations between TAD and MAD characteristics and the relationship to ventricular arrhythmias (nonsustained/sustained ventricular tachycardias and aborted cardiac arrest).
Results
We included 84 patients (mean age: 48 ± 16 years; 63% female). We observed TAD in 42 (50%). Patients with TAD were older (age 52 ± 16 years vs. 43 ± 15 years; p = 0.02), had greater circumferential extent of MAD (164 ± 57° vs. 115 ± 58°; p = 0.002), greater maximum longitudinal MAD distance (9.4 ± 2.9 mm vs. 6.2 ± 2.8 mm; p < 0.001), and more frequent mitral valve prolapse (n = 39 [92%] vs. n = 24 [57%]; p < 0.001). Ventricular arrhythmias had occurred in 34 patients (41%), who were younger (age 39 ± 14 years vs. 54 ± 14 years; p < 0.001) and had lower prevalence of TAD (n = 22 [29%] vs. n = 12 [52%]; p = 0.03). TAD was not associated with ventricular arrhythmias when adjusted for age (odds ratio adjusted for age: 0.54; 95% confidence interval: 0.20 to 1.45; p = 0.22).
Conclusions
We report for the first time the existence of right-sided annulus disjunction as a common finding in patients with MAD. TAD was associated with more severe left-sided annulus disjunction and mitral valve prolapse, but not with ventricular arrhythmias.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1535-1543
Aabel EW, Chivulescu M, Dejgaard LA, Ribe M, ... Lie ØH, Haugaa KH
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1535-1543 | PMID: 33744128
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Are Training Programs Ready for the Rapid Adoption of CCTA?: CBME in CCTA.

Chow BJW, Yam Y, Alenazy A, Crean AM, ... Hossain A, Small GR
Objectives
This study sought to assess training volumes and its relationship to learning and identify potential new thresholds for determining expertise.
Background
Competency-based medical education (CBME) is being rapidly adopted and therefore training programs will need to adapt and identify new and novel methods of defining, measuring, and assessing clinical skills.
Methods
Consecutive cardiac computed tomography (CT) studies were interpreted independently by trainees and expert readers, and their interpretations (Agatston score, coronary artery disease severity, and Coronary Artery Disease Reporting and Data System) were collected. Kappa agreements were measured between trainees and experts for every 50 consecutive cases. Agreements between trainees and experts were tracked and compared with the agreement between expert readers.
Results
A total of 36 trainees interpreted 14,432 cardiac CT studies. Agreement between trainees and experts increased with CT case volumes, but trainees learned at different rates. Using a threshold for expertise, skill of measuring coronary calcification was achieved within 50 cases, but expertise for coronary CT angiography appeared to require a mean case volume of 750, comprising 400 abnormal cases.
Conclusions
Current volume-based training guidelines may be insufficient and higher case volumes may be required. We demonstrate that tracking cardiac CT learners is feasible and that CBME could be incorporated into CT training programs.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1584-1593
Chow BJW, Yam Y, Alenazy A, Crean AM, ... Hossain A, Small GR
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1584-1593 | PMID: 33865790
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Myocardial Fibrosis and Inflammation by CMR Predict Cardiovascular Outcome in People Living With HIV.

de Leuw P, Arendt CT, Haberl AE, Froadinadl D, ... Nagel E, Puntmann VO
Objectives
The goal of this study was to examine prognostic relationships between cardiac imaging measures and cardiovascular outcome in people living with human immunodeficiency virus (HIV) (PLWH) on highly active antiretroviral therapy (HAART).
Background
PLWH have a higher prevalence of cardiovascular disease and heart failure (HF) compared with the noninfected population. The pathophysiological drivers of myocardial dysfunction and worse cardiovascular outcome in HIV remain poorly understood.
Methods
This prospective observational longitudinal study included consecutive PLWH on long-term HAART undergoing cardiac magnetic resonance (CMR) examination for assessment of myocardial volumes and function, T1 and T2 mapping, perfusion, and scar. Time-to-event analysis was performed from the index CMR examination to the first single event per patient. The primary endpoint was an adjudicated adverse cardiovascular event (cardiovascular mortality, nonfatal acute coronary syndrome, an appropriate device discharge, or a documented HF hospitalization).
Results
A total of 156 participants (62% male; age [median, interquartile range]: 50 years [42 to 57 years]) were included. During a median follow-up of 13 months (9 to 19 months), 24 events were observed (4 HF deaths, 1 sudden cardiac death, 2 nonfatal acute myocardial infarction, 1 appropriate device discharge, and 16 HF hospitalizations). Patients with events had higher native T1 (median [interquartile range]: 1,149 ms [1,115 to 1,163 ms] vs. 1,110 ms [1,075 to 1,138 ms]); native T2 (40 ms [38 to 41 ms] vs. 37 ms [36 to 39 ms]); left ventricular (LV) mass index (65 g/m2 [49 to 77 g/m2] vs. 57 g/m2 [49 to 64 g/m2]), and N-terminal pro-B-type natriuretic peptide (109 pg/l [25 to 337 pg/l] vs. 48 pg/l [23 to 82 pg/l]) (all p < 0.05). In multivariable analyses, native T1 was independently predictive of adverse events (chi-square test, 15.9; p < 0.001; native T1 [10 ms] hazard ratio [95% confidence interval]: 1.20 [1.08 to 1.33]; p = 0.001), followed by a model that also included LV mass (chi-square test, 17.1; p < 0.001). Traditional cardiovascular risk scores were not predictive of the adverse events.
Conclusions
Our findings reveal important prognostic associations of diffuse myocardial fibrosis and LV remodeling in PLWH. These results may support development of personalized approaches to screening and early intervention to reduce the burden of HF in PLWH (International T1 Multicenter Outcome Study; NCT03749343).

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1548-1557
de Leuw P, Arendt CT, Haberl AE, Froadinadl D, ... Nagel E, Puntmann VO
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1548-1557 | PMID: 33865770
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Role of Cardiac CT in Pre-Procedure Planning for Transcatheter Mitral Valve Replacement.

Ge Y, Gupta S, Fentanes E, Aghayev A, ... Shah P, Blankstein R
Objectives
This study sought to evaluate cardiac computed tomography (CCT) findings and their clinical impact among patients being considered for transcatheter mitral valve replacement (TMVR).
Background
CCT is used to evaluate whether patients are candidates for TMVR, but limited data exist on the yield of such tests.
Methods
Patients referred for pre-procedural CCT for TMVR planning in the context of failing mitral bioprosthetic valves, annuloplasty rings, and severe native valve disease with annular calcification were included in this study. CCT findings were analyzed to evaluate for suitability for TMVR. In the subset of patients who underwent TMVR, echocardiographic and procedural characteristics were recorded.
Results
Among 80 patients who underwent pre-procedural CCT, the mean age was 71.8 ± 11.4 years, 60% were women, and the mean Society of Thoracic Surgeon score was 9.4 ± 6.7. Most cases were referred for valve-in-native annular calcification planning (n = 43), followed by valve-in-valve (n = 29), and valve-in-ring procedures (n = 8). A total of 51 (64%) patients did not undergo TMVR, 37 of whom had high-risk features identified on CCT. The most common reason for exclusion was related to large annular size, followed by heightened risk of left ventricular outflow tract (LVOT) obstruction. Among 29 patients (36%) who underwent TMVR, the 30-day mortality rate was 17%. Five patients experienced LVOT obstruction, 4 of whom were predicted by CCT. Following TMVR, 5 patients had at least moderate peri-valvular regurgitation.
Conclusions
A minority of patients referred for TMVR planning ultimately undergo the procedure. CCT identifies unsuitable anatomy and leads to exclusion in a significant number of cases.

Copyright © 2021 American College of Cardiology Foundation. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1571-1580
Ge Y, Gupta S, Fentanes E, Aghayev A, ... Shah P, Blankstein R
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1571-1580 | PMID: 33865768
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prognostic Implication of RV Coupling to Pulmonary Circulation for Successful Weaning From Extracorporeal Membrane Oxygenation.

Kim D, Park Y, Choi KH, Park TK, ... Jeon ES, Yang JH
Objectives
The aim of this study was to explore if right ventricular (RV) contractile function and its coupling to pulmonary circulation (PC) were associated with successful weaning from venoarterial-extracorporeal membrane oxygenation (VA-ECMO) at maintenance of pump flow.
Background
Limited data are available on predictors of successful weaning from VA-ECMO.
Methods
A total of 79 patients with cardiogenic shock underwent transthoracic echocardiography to evaluate weaning from ECMO and were prospectively enrolled between 2016 and 2019. The noninvasively measured RV-PC coupling index was acquired by indexing tricuspid annular S\' velocity, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and RV free-wall longitudinal strain (FWLS) to right ventricular systolic pressure (RVSP).
Results
Transthoracic echocardiography was performed at a median 3.0 days (range 1 to 6 days) after ECMO initiation at a median ECMO flow of 3.2 l/min (range 3.0 to 3.6 l/min). The RV-PC coupling matrix, tricuspid annular S\'/RVSP, TAPSE/RVSP, and RV FWLS/RVSP exhibited satisfactory predictive performances for predicting successful weaning from ECMO. Using the best cutoff values derived from the area under the receiver-operator characteristic curve, tricuspid annular S\'/RVSP demonstrated a significantly better predictive performance than conventional echocardiographic parameters (left ventricular ejection fraction >20%, left ventricular outflow tract time-velocity integral ≥10 cm, and mitral annular S\' ≥6 cm/s).
Conclusions
Echocardiographic RV-PC coupling metrics exhibited a significantly better performance for predicting successful weaning from VA ECMO compared with conventional echocardiographic criteria at maintenance of pump flow.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1523-1531
Kim D, Park Y, Choi KH, Park TK, ... Jeon ES, Yang JH
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1523-1531 | PMID: 33865793
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prognostic Value of Feature-Tracking Right Ventricular Longitudinal Strain in Severe Functional Tricuspid Regurgitation: A Multicenter Study.

Romano S, Dell\'atti D, Judd RM, Kim RJ, ... Hahn RT, Farzaneh-Far A
Objectives
This study sought to evaluate the prognostic value of cardiac magnetic resonance (CMR) feature-tracking-derived right ventricular (RV) free wall longitudinal strain (RVFWLS) in a large multicenter population of patients with severe functional tricuspid regurgitation.
Background
Tricuspid regurgitation imposes a volume overload on the RV that can lead to progressive RV dilation and dysfunction. Overt RV dysfunction is associated with poor prognosis and increased operative risk. Abnormalities of myocardial strain may provide the earliest evidence of ventricular dysfunction. CMR feature-tracking techniques now allow assessment of strain from routine cine images, without specialized pulse sequences. Whether abnormalities of RV strain measured using CMR feature tracking have prognostic value in patients with tricuspid regurgitation is unknown.
Methods
Consecutive patients with severe functional tricuspid regurgitation undergoing CMR at 4 U.S. medical centers were included in this study. Feature-tracking RVFWLS was calculated from 4-chamber cine views. The primary endpoint was all-cause death. Cox proportional hazards regression modeling was used to examine the independent association between RVFWLS and death. The incremental prognostic value of RVFWLS was assessed in nested models.
Results
Of the 544 patients in this study, 128 died during a median follow-up of 6 years. By Kaplan-Meier analysis, patients with RVFWLS ≥median (-16%) had significantly reduced event-free survival compared with those with RVFWLS <median (log-rank p < 0.001). By Cox multivariable regression modeling, RVFWLS was associated with increased risk-of-death after adjustment for clinical and imaging risk factors, including RV size and ejection fraction (hazard ratio: 1.14 per %; p < 0.001). Addition of RVFWLS in this model resulted in significant improvement in the global chi-square (31 to 78; p < 0.001).
Conclusions
CMR feature-tracking-derived RVFWLS is an independent predictor of mortality in patients with severe functional tricuspid regurgitation, incremental to common clinical and imaging risk factors.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1561-1568
Romano S, Dell'atti D, Judd RM, Kim RJ, ... Hahn RT, Farzaneh-Far A
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1561-1568 | PMID: 33865769
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:
Abstract

Prognostic Value of RCA Pericoronary Adipose Tissue CT-Attenuation Beyond High-Risk Plaques, Plaque Volume, and Ischemia.

van Diemen PA, Bom MJ, Driessen RS, Schumacher SP, ... Danad I, Knaapen P
Objectives
This study was designed to assess the prognostic value of pericoronary adipose tissue computed tomography attenuation (PCATa) beyond quantitative coronary computed tomography angiography (CCTA)-derived plaque volume and positron emission tomography (PET) determined ischemia.
Background
Inflammation plays a crucial role in atherosclerosis. PCATa has been shown to assess coronary-specific inflammation and is of prognostic value in patients with suspected coronary artery disease (CAD).
Methods
A total of 539 patients who underwent CCTA and [15O]H2O PET perfusion imaging because of suspected CAD were included. Imaging assessment included coronary artery calcium score (CACS), presence of obstructive CAD (≥50% stenosis) and high-risk plaques (HRPs), total plaque volume (TPV), calcified/noncalcified plaque volume (CPV/NCPV), PCATa, and myocardial ischemia. The endpoint was a composite of death and nonfatal myocardial infarction. Prognostic thresholds were determined for quantitative CCTA variables.
Results
During a median follow-up of 5.0 (interquartile range: 4.7 to 5.0) years, 33 events occurred. CACS >59 Agatston units, obstructive CAD, HRPs, TPV >220 mm3, CPV >110 mm3, NCPV >85 mm3, and myocardial ischemia were associated with shorter time to the endpoint with unadjusted hazard ratios (HRs) of 4.17 (95% confidence interval [CI]: 1.80 to 9.64), 4.88 (95% CI: 1.88 to 12.65), 3.41 (95% CI: 1.72 to 6.75), 7.91 (95% CI: 3.05 to 20.49), 5.82 (95% CI: 2.40 to 14.10), 8.07 (95% CI: 3.33 to 19.55), and 4.25 (95% CI: 1.84 to 9.78), respectively (p < 0.05 for all). Right coronary artery (RCA) PCATa above scanner specific thresholds was associated with worse prognosis (unadjusted HR: 2.84; 95% CI: 1.44 to 5.63; p = 0.003), whereas left anterior descending artery and circumflex artery PCATa were not related to outcome. RCA PCATa above scanner specific thresholds retained is prognostic value adjusted for imaging variables and clinical characteristics associated with the endpoint (adjusted HR: 2.45; 95% CI: 1.23 to 4.93; p = 0.011).
Conclusions
Parameters associated with atherosclerotic burden and ischemia were more strongly associated with outcome than RCA PCATa. Nonetheless, RCA PCATa was of prognostic value beyond clinical characteristics, CACS, obstructive CAD, HRPs, TPV, CPV, NCPV, and ischemia.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 30 Jul 2021; 14:1598-1610
van Diemen PA, Bom MJ, Driessen RS, Schumacher SP, ... Danad I, Knaapen P
JACC Cardiovasc Imaging: 30 Jul 2021; 14:1598-1610 | PMID: 33958312
Go to: DOI | PubMed | PDF | Google Scholar |
Impact:

This program is still in alpha version.