Topic: Imaging

Abstract

Comorbidity burden in patients undergoing left atrial appendage closure.

Sanjoy S, Choi YH, Holmes D, Herrman H, ... Mamas M, Bagur R
Objective
To estimate the risk of in-hospital complications after left atrial appendage closure (LAAC) in relationship with comorbidity burden.
Methods
Cohort-based observational study using the US National Inpatient Sample database, 1 October 2015 to 31 December 2017. The main outcome of interest was the occurrence of in-hospital major adverse events (MAE) defined as the composite of bleeding complications, acute kidney injury, vascular complications, cardiac complications and postprocedural stroke. Comorbidity burden and thromboembolic risk were assessed by the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Score (ECS) and CHADS-VASc score. MAE were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. The associations of comorbidity with in-hospital MAE were evaluated using logistic regression models.
Results
A total of 3294 hospitalisations were identified, among these, the mean age was 75.7±8.2 years, 60% were male and 86% whites. The mean CHADS-VASc score was 4.3±1.5 and 29.5% of the patients had previous stroke or transient ischaemic attack. The mean CCI and ECS were 2.2±1.9 and 9.7±5.8, respectively. The overall composite rate of in-hospital MAE after LAAC was 4.6%. Females and non-whites had about 1.5 higher odds of in-hospital AEs as well participants with higher CCI (adjusted OR (aOR): 1.19, 95% CI: 1.13 to 1.24, p<0.001), ECS (aOR: 1.06, 95% CI: 1.05 to 1.08, p<0.001) and CHADS-VASc score (aOR: 1.08, 95% CI: 1.02 to 1.15, p=0.01) were significantly associated with in-hospital MAE.
Conclusion
In this large cohort of LAAC patients, the majority of them had significant comorbidity burden. In-hospital MAE occurred in 4.6% and female patients, non-whites and those with higher burden of comorbidities were at higher risk of in-hospital MAE after LAAC.

© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 22 Nov 2020; epub ahead of print
Sanjoy S, Choi YH, Holmes D, Herrman H, ... Mamas M, Bagur R
Heart: 22 Nov 2020; epub ahead of print | PMID: 33229360
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Abstract

Subclinical left atrial dysfunction profiles for prediction of cardiac outcome in the general population.

Cauwenberghs N, Haddad F, Sabovčik F, Kobayashi Y, ... Voigt JU, Kuznetsova T
Objective
Echocardiographic definitions of subclinical left atrial dysfunction based on epidemiological data remain scarce. In this population study, we derived outcome-driven thresholds for echocardiographic left atrial function parameters discriminating between normal and abnormal values.
Methods
In 1306 individuals (mean age, 50.7 years; 51.6% women), we echocardiographically assessed left atrial function and LV global longitudinal strain. We derived cut-off values for left atrial emptying fraction (LAEF), left atrial function index (LAFI) and left atrial reservoir strain (LARS) to define left atrial dysfunction using receiver-operating curve threshold analysis. Main outcome was the incidence of cardiac events and atrial fibrillation (AFib) on average 8.5 years later.
Results
For prediction of new-onset AFib, left atrial cut-offs yielding the best balance between sensitivity and specificity (highest Youden index) were: LAEF less than 55%, LAFI less than 40.5 and LARS less than 23%. Applying these cut-offs, abnormal LAEF, LAFI and LARS were, respectively, present in 27, 37.1 and 18.1% of the cohort. Abnormal LARS (<23%) was independently associated with higher risk for cardiac events and new-onset AFib (P ≤ 0.012). Participants with both abnormal LAEF and LARS presented a significantly higher risk to develop cardiac events (hazard ratio: 2.10; P = 0.014) and AFib (hazard ratio: 6.45; P = 0.0036) than normal counterparts. The concomitant presence of an impaired LARS and LV global longitudinal strain improved prognostic accuracy beyond a clinical risk model for cardiac events and the CHARGE-AF Risk Score for AFib.
Conclusion
Left atrial dysfunction based on outcome-driven thresholds predicted cardiac events and AFib independent of conventional risk factors. Screening for subclinical left atrial and LV systolic dysfunction may enhance cardiac disease prediction in the community.



J Hypertens: 29 Nov 2020; 38:2465-2474
Cauwenberghs N, Haddad F, Sabovčik F, Kobayashi Y, ... Voigt JU, Kuznetsova T
J Hypertens: 29 Nov 2020; 38:2465-2474 | PMID: 32649644
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Abstract

Cryoballoon Ablation and Bipolar Voltage Mapping in Patients With Left Atrial Appendage Occlusion Devices.

Huang HD, Krishnan K, Sharma PS, Kavinsky CJ, ... Larsen TR, Trohman RG

Left atrial appendage occlusion is utilized as a second line therapy to long-term oral anticoagulation in appropriately selected patients with atrial fibrillation (AF). We examined the feasibility of cryoballoon (CB) pulmonary vein isolation (PVI) subsequent to Watchman device implantation. The study prospectively identified patients with Watchman devices (>90 days old) who underwent CB-PVI ablation between 2018 and 2019. Twelve consecutive patients (male 50%; mean age 71 ± 9 years; CHADS-VASc score 3.4 ± 1.1) underwent CB-PVI procedures after Watchman device implantation (mean 182 ± 82 days). Acute PVI was achieved in 100% of patients. All patients had evidence of complete (n = 9) or partial (n = 3) endothelialization of the surface of the Watchman device with conductive tissue properties demonstrated during electrophysiologic testing. There were no major procedure-related complications including death, stroke, pericardial effusion, device dislodgment, device thrombus, or new or increasing peri-device leak. Mean peri-device leak size (45-day postimplant: 0.06 ± 0.09 mm vs Post-PVI: 0.04 ± 0.06 mm; p = 0.61) remained unchanged. Two patients had recurrence of AF after the 90-day blanking period (13.2 ± 6.6 months). One patient underwent a redo ablation procedure for recurrent AF. This pilot study suggests the potential feasibility of CB-PVI ablation in patients with chronic Watchman left atrial appendage occlusion devices. Larger prospective studies are needed to confirm the clinical efficacy and safety of this approach.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:99-104
Huang HD, Krishnan K, Sharma PS, Kavinsky CJ, ... Larsen TR, Trohman RG
Am J Cardiol: 14 Nov 2020; 135:99-104 | PMID: 32866447
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Abstract

Worth Remembering: Cardiac Memory Presenting as Deep Anterior T-Wave Inversions Explained by Intermittent Left Bundle Branch Block.

Pierce JB, Rosenthal J, Stone NJ

Cardiac memory is a common cause of deep T-wave inversions (TWI) in the anterior precordial leads and can be difficult to distinguish from alternative causes of TWI such as myocardial ischemia. Cardiac memory is generally a benign condition except in the setting of prolonged QT when it can contribute to the precipitation of torsades de pointes. Herein, we describe the presentation and clinical course of a case of cardiac memory due to intermittent left bundle branch block (LBBB) that presented asymptomatically to our outpatient cardiology clinic with deep anterior TWI. We discuss common causes of and mechanisms underlying cardiac memory and how to distinguish it from alternative causes of TWI based on 12-lead electrocardiogram. In conclusion, intermittent LBBB is an under-recognized cause of cardiac memory that can present as deep anterior TWI mimicking cardiac ischemia, and awareness of this clinical entity may help prevent unnecessary invasive and expensive testing on otherwise healthy patients.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2020; 135:174-176
Pierce JB, Rosenthal J, Stone NJ
Am J Cardiol: 14 Nov 2020; 135:174-176 | PMID: 32866450
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Abstract

Effectiveness of alcohol septal ablation for hypertrophic obstructive cardiomyopathy in patients with late gadolinium enhancement on cardiac magnetic resonance.

Polaková E, Liebregts M, Marková N, Adla T, ... Bonaventura J, Veselka J
Background
According to European guidelines, alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) may be less effective in patients with extensive septal scarring on cardiac magnetic resonance (CMR). This study aimed to analyze the impact of late gadolinium enhancement (LGE) on CMR on the effectiveness of ASA.
Method
We conducted an observational retrospective study involving adult patients with symptomatic drug-refractory HOCM who underwent CMR before ASA at two European centres from May 2010 through June 2019. Patients were compared in binary format based on LGE presence. Moreover, a subanalysis focused on patients with septal fibrosis was performed. The effectiveness of ASA was evaluated by echocardiographic, ECG and clinical findings.
Results
Of the 113 study patients, 54 (48%) had LGE on CMR. The LGE quantification performed in 29 patients revealed septal fibrosis in 17. The mean follow-up was 4.4 ± 2.6 years. Baseline parameters were similar between groups except for basal septal thickness that was greater in LGE+ group (21.1 ± 3.9 mm for LGE+ vs. 19.2 ± 3.2 mm for LGE-: p = .005). ASA improved symptoms in all groups and reduced left ventricular outflow tract obstruction (LVOTO) (delta gradient reduction: LGE+: 62 ± 37.3%; septal LGE+: 75.6 ± 20.8%; LGE-: 72.5 ± 21.0%). However, 13% of the LGE+ and 2% of the LGE- group had residual LVOTO above 30 mmHg (p = .027).
Conclusion
ASA was effective in all patients with HOCM, whether they had LGE on CMR or not and whether they had septal fibrosis or not.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Nov 2020; 319:101-105
Polaková E, Liebregts M, Marková N, Adla T, ... Bonaventura J, Veselka J
Int J Cardiol: 14 Nov 2020; 319:101-105 | PMID: 32682963
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Abstract

Effectiveness and safety of same day discharge after left atrial appendage closure under moderate conscious sedation.

Marmagkiolis K, Ates I, Kose G, Iliescu C, Cilingiroglu M
Background
Left atrial appendage occlusion (LAAO) using Watchman device has become a world-wide, well-established therapeutic alternative to chronic systemic oral anticoagulation in patient who are at high-risk of bleeding with paroxysmal (PAF) or chronic atrial fibrillation (Afib). Currently, LAAO procedures are performed under general anesthesia (GA) and patients stay overnight post procedure in the United States. We aimed to present the effectiveness and safety of same day discharge following LAAO under moderate conscious sedation (MCS) in patients without procedural complications.
Methods
A total of 112 patients between August 2019 and May 2020 with elevated CHA DS VASc (median score of 3) underwent transesophageal echocardiography (TEE)-guided LAAO with FDA approved Watchman (Boston Scientific, MN) under MCS and discharged home on the same day 6 hr following their post procedural transthoracic echocardiogram (TTE) evaluations. All patients had next day TTE and follow up at the cardiology clinic. We prospectively evaluated clinical and procedural outcomes using medical records of these patients.
Results
Among all the patients, the mean age was 83.5 ± 8.5 years, 45 (40%) were women. Procedural duration, device implant time and fluoroscopic times were 45 ± 8.6, 14.5 ± 7.8 and 10.2 ± 1.2 min, respectively. The median required dosage of propofol was 105 ± 2.8 mg. No complications arose from MCS. There was no need for conversion to GA in any of the patients during the procedure. All patients were able to be discharged 6 hr following their TTE evaluation post procedure. There were no procedural complications.
Conclusions
Same day discharge following LAAO closure seems to be safe and effective in patients without procedural complications. LAAO can also be performed safely and effectively under moderate conscious sedation. Applying moderate conscious sedation may simplify the LAAO procedure, reduce procedural time, procedural costs and hospital stay while increasing overall patient satisfaction.

© 2020 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 15 Nov 2020; epub ahead of print
Marmagkiolis K, Ates I, Kose G, Iliescu C, Cilingiroglu M
Catheter Cardiovasc Interv: 15 Nov 2020; epub ahead of print | PMID: 33197110
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Abstract

Hemodynamic performance of the balloon-expandable SAPIEN 3 valve as assessed by cardiac magnetic resonance.

Nunes Ferreira-Neto A, Merten C, Beurich HW, Zachow D, ... Rodés-Cabau J, Abdel-Wahab M
Background
Scarce data exist on transcatheter heart valve (THV) performance evaluated by cardiac magnetic resonance (CMR) in newer generation THV patients. Furthermore, it has been suggested that echocardiographic evaluation after TAVR may inaccurately assess residual AR in some patients. This study aimed to determine the incidence and severity of aortic regurgitation (AR) assessed by CMR in patients undergoing TAVR with the SAPIEN 3 valve, and evaluate the agreement between CMR and transthoracic echocardiography (TTE) on the assessment of AR severity in such patients.
Methods
This multicentric observational study included 146 SAPIEN 3 patients with TTE and CMR within the month following their procedure. According to the CMR regurgitation fraction (RF), AR was considered mild and moderate-severe if the RF was 15-<30% and ≥ 30%, respectively. TTE exams followed VARC-2 recommendations.
Results
By CMR, SAPIEN 3 recipients displayed a mean RF of 5.0 ± 6.1%, and mild and moderate-severe AR rates of 3.4% and 0.7%, respectively. The agreement between CMR-TTE was modest (weighted κ = 0.2640, p<0.001), due to an overestimation of AR severity by TTE. A historical cohort of 139 SAPIEN XT patients with a post-procedure CMR, displayed a mean RF of 9.6 ± 10.7% and mild and moderate-severe AR rates of 18.7% and 3.6%, respectively (p < .001 vs. SAPIEN 3 group).
Conclusions
SAPIEN 3 recipients exhibited very low rates of residual AR by CMR, suggesting a surgical-like performance regarding AR with this newer generation THV. TTE tended to overestimate the severity of AR, particularly among mild AR patients.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Nov 2020; 320:128-132
Nunes Ferreira-Neto A, Merten C, Beurich HW, Zachow D, ... Rodés-Cabau J, Abdel-Wahab M
Int J Cardiol: 30 Nov 2020; 320:128-132 | PMID: 32702409
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Abstract

The combined effects of cardiac geometry, microcirculation, and tissue characteristics on cardiac systolic and diastolic function in subclinical diabetes mellitus-related cardiomyopathy.

Jiang L, Wang J, Liu X, Li ZL, ... Guo YK, Yang ZG
Background
Diabetes mellitus-related cardiomyopathy has recently been described as a distinct progression of left ventricular (LV) systolic and diastolic dysfunction. Pathological changes in the myocardium may explain the development of two different phenotypes. We evaluated the effects of LV geometry, myocardial microcirculation, and tissue characteristics on cardiac deformation in patients with subclinical type 2 diabetes mellitus (T2DM) utilizing multiparametric cardiac magnetic resonance (CMR) imaging.
Methods
A total of 135 T2DM patients and 55 matched controls were prospectively enrolled and performed multiparametric CMR examination. CMR-derived parameters including cardiac geometry, function, microvascular perfusion, T1 mapping, T2 mapping, and strain were analyzed and compared between T2DM patients and controls.
Results
The univariable and multivariable analysis of systolic and diastolic function revealed that longer duration of diabetes was associated with decreased longitudinal peak systolic strain rate (PSSR-L) (β = 0.195, p = .013), and higher remodeling index and higher extracellular volume (ECV) tended to correlate with decreased longitudinal peak diastolic strain rate (PDSR-L) (remodeling index, β = -0.339, p = .000; ECV, β = -0.172, p = .026), whereas microvascular perfusion index and T2 value affected both PSSR-L (perfusion index, β = -0.328, p = .000; T2 value, β = 0.306, p = .000) and PDSR-L (perfusion index, β = 0.209, p = .004; T2 value, β = -0.275, p = .000) simultaneously.
Conclusions
The LV concentric remodeling and myocardial fibrosis correlated with diastolic function, and perfusion function and myocardial edema were associated with both LV systolic and diastolic function.

Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Nov 2020; 320:112-118
Jiang L, Wang J, Liu X, Li ZL, ... Guo YK, Yang ZG
Int J Cardiol: 30 Nov 2020; 320:112-118 | PMID: 32679137
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Abstract

Left ventricular circumferential strain and coronary microvascular dysfunction: A report from the Women\'s Ischemia Syndrome Evaluation Coronary Vascular Dysfunction (WISE-CVD) Project.

Tamarappoo B, Samuel TJ, Elboudwarej O, Thomson LEJ, ... Nelson MD, Merz CNB
Aims
Women with ischemia but no obstructive coronary artery disease (INOCA) often have coronary microvascular dysfunction (CMD). Left ventricular (LV) circumferential strain (CS) is often lower in INOCA compared to healthy controls; however, it remains unclear whether CS differs between women with and without CMD. We hypothesized that CS would be lower in women with CMD, consistent with CMD-induced LV mechanical dysfunction.
Methods and results
Cardiac magnetic resonance (cMR) images were examined from women enrolled in the Women\'s Ischemia Syndrome Evaluation-Coronary Vascular Dysfunction Project. CS by feature tracking in INOCA women with CMD, defined as myocardial perfusion reserve index (MPRI) <1.84 during adenosine-stress perfusion cMR, was compared with CS in women without CMD. In a subset who had invasive coronary function testing (CFT), the relationship between CS and CFT metrics, LV ejection fraction (LVEF) and cardiovascular risk factors was investigated. Among 317 women with INOCA, 174 (55%) had CMD measured by MPRI. CS was greater in women with CMD compared to those without CMD (23.2 ± 2.5% vs. 22.1 ± 3.0%, respectively, P = 0.001). In the subset with CFT (n = 153), greater CS was associated with increased likelihood of reduced vasodilator capacity (OR = 1.33, 95%CI = 1.02-1.72, p = 0.03) and discriminated abnormal vs. normal coronary vascular function compared to CAD risk factors, LVEF and LV concentricity (AUC: 0.82 [0.73-0.96 95%CI] vs. 0.65 [0.60-0.71 95%CI], respectively, P = 0.007).
Conclusion
The data indicate that LV circumferential strain is related to and predicts CMD, although in a direction contrary with our hypothesis, which may represent an early sign of LV mechanical dysfunction in CMD.

Copyright © 2020 Elsevier Ireland Ltd. All rights reserved.

Int J Cardiol: 13 Nov 2020; epub ahead of print
Tamarappoo B, Samuel TJ, Elboudwarej O, Thomson LEJ, ... Nelson MD, Merz CNB
Int J Cardiol: 13 Nov 2020; epub ahead of print | PMID: 33202262
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Abstract

Effect of tricuspid regurgitation and right ventricular dysfunction on long-term mortality in patients undergoing cardiac devices implantation: >10-year follow-up study.

Papageorgiou N, Falconer D, Wyeth N, Lloyd G, ... Chow AW, Bhattacharyya S
Background
The long-term effect of tricuspid regurgitation (TR) after device implantation on long-term mortality remains unknown. In the present study, we sought to examine whether patients undergoing an implantable cardiac device procedure (pacemaker, cardiac defibrillator or cardiac resynchronisation therapy) have an increased risk of TR and to determine the effect of this on long-term survival.
Methods
A total of 304 patients who underwent device implant and had pre- and post-implant transthoracic echocardiogram were included in the analysis. All-cause mortality was the study endpoint over a follow-up period of median 11.6 years.
Results
New ≥ moderate tricuspid regurgitation post-device implantation developed in 66/304 (21.7%) patients. New right ventricular dysfunction post-device implantation occurred in 59/304 (19.4%) patients. Independent predictors of new RV dysfunction were ischaemic heart disease (OR 4.23, 95% CI 1.58 - 11.33, p = 0.004), left ventricular impairment (OR 2.74, 95% CI 5.41 - 30.00, p < 0.0001) and new ≥ moderate TR (OR 7.72, 95% CI 3.27 - 18.23, p < 0.001). Independent predictors of mortality were new ≥ moderate TR [HR: 3.14 (95% CI 1.29 - 7.63) p = 0.01] and new RV impairment [HR: 2.82 (95% CI 1.33 - 5.98) p = 0.01.
Conclusions
Worsening TR and RV dysfunction post-device implantation is common. New post-implant ≥ moderate TR is associated with increased risk of new RV impairment and poor long term (>10 years) survival.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Nov 2020; 319:52-56
Papageorgiou N, Falconer D, Wyeth N, Lloyd G, ... Chow AW, Bhattacharyya S
Int J Cardiol: 14 Nov 2020; 319:52-56 | PMID: 32470533
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Abstract

Closing gigantic left atrial appendage using a LAmbre Closure System: first implant experience in North America.

Inohara T, Tsang MY, Lee C, Saw J

Despite maturing experience and growing procedural familiarity, there remain challenges in percutaneous left atrial appendage (LAA) closure due to anatomical complexities. We report a complex and extremely large LAA that was successfully closed percutaneously using a LAmbre Closure System (Lifetech Scientific Corp., Shenzhen, China). Cardiac computed tomography angiography demonstrated a gigantic multi-lobed LAA measuring 48 by 45.3mm at the level of the ostium, that can not be occluded by the currently approved LAA closure devices in Canada. A LAmbre Closure System 30/50mm (lobe/disc) was then successfully deployed under fluoroscopy and transesophageal echocardiogram guidance without procedure-related complications. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print
Inohara T, Tsang MY, Lee C, Saw J
J Cardiovasc Electrophysiol: 10 Nov 2020; epub ahead of print | PMID: 33179356
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Abstract

Echocardiography and cardiac magnetic resonance in children with repaired tetralogy of Fallot: New insights in cardiac mechanics and exercise capacity.

Avesani M, Borrelli N, Krupickova S, Sabatino J, ... Iliceto S, Di Salvo G
Background
Pulmonary regurgitation (PR) and right ventricular (RV) dilatation and disfunction are common in patients with repaired Tetralogy of Fallot (r-TOF).
Aims
To compare Echo data with the gold standard CMR in a paediatric population of r-TOF with significant PR, to assess the reliability of standard and advanced echo parameters. In addition, to evaluate their correlation with peak oxygen consumption (VO).
Methods and results
All patients underwent standard echo-Doppler study, speckle tracking analysis, and CMR to assess PR and RV size and function. Thirty-six patients underwent also cardiopulmonary exercise test. Fourty-six patients (aged 13.7 ± 3.0) were included. Echo derived RV areas correlated with CMR RV volumes (p < .0001, r = 0.72). RV end-diastolic area > 21.9 cm/m had a good sensitivity (83.3%) and specificity (73.5%) to identify a RV end-diastolic volume ≥ 150 ml/m. RVEF was preserved in all patients, while TAPSE was reduced in 78.2% and RVGLS in 60.8%. Flow-reversal in pulmonary branches showed a sensitivity of 95.8% and a specificity of 59.1% to identify CMR pulmonary regurgitant fraction (RF) ≥ 35%. None of the CMR parameters correlated with peak VO. Among the Echo data only right atrial strain (RAS) correlated with peak VO Conclusion: In children, flow-reversal in pulmonary branches identifies hemodynamically significant RF with a good sensitivity but poor specificity. RV area by echocardiogram is a valid first-line parameter to screen RV dilation. RV longitudinal systolic dysfunction coexists with a still preserved EF. RAS correlates strongly with peak VO and should be added in their follow up.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Dec 2020; 321:144-149
Avesani M, Borrelli N, Krupickova S, Sabatino J, ... Iliceto S, Di Salvo G
Int J Cardiol: 14 Dec 2020; 321:144-149 | PMID: 32702408
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Abstract

Lower left ventricular ejection fraction and higher serum angiotensin-converting enzyme activity are associated with histopathological diagnosis by endomyocardial biopsy in patients with cardiac sarcoidosis.

Komoriyama H, Omote K, Nagai T, Kato Y, ... Ishibashi-Ueda H, Anzai T
Background
The histopathological diagnosis of cardiac sarcoidosis (CS) is challenging because of sampling error in endomyocardial biopsy (EMB) and the determinants of positive EMB are unclear. Reduced left ventricular ejection fraction (LVEF) is a simple parameter of the extent of myocardial damage, and higher serum angiotensin-converting enzyme (ACE) activity would indicate the spread of disease activity in CS patients. Thus, we sought to examine whether these parameters are related to the histopathological diagnosis of CS by EMB.
Methods
A total of 94 consecutive clinically diagnosed CS patients between August 1986 and March 2019 who were admitted to two academic hospitals were examined. We determined EMB as positive if non-caseating epithelioid granulomas were confirmed in the myocardial tissue. Patients were divided into two groups according to positive (n = 37) and negative (n = 57) EMB. We assessed the relationship between LVEF, serum ACE activity and positive EMB.
Results
Multivariable analysis revealed that both LVEF and serum ACE were independently associated with positive EMB (OR 0.83, 95% CI 0.70-0.99; OR 1.39, 95% CI 1.02-1.90, respectively). Moreover, patients with both lower LVEF (<37%, median) and higher ACE activity (≥13.5 IU/L, median) had the highest frequency of positive EMB (p = .003). The combination of lower LVEF and higher serum ACE showed better specificity (91.2%) and positive predictive value (73.7%) than either LVEF or serum ACE alone for positive EMB.
Conclusions
Lower LVEF and higher serum ACE activity were associated with positive EMB, suggesting that these parameters might be useful for predicting positive EMB in CS patients.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Dec 2020; 321:113-117
Komoriyama H, Omote K, Nagai T, Kato Y, ... Ishibashi-Ueda H, Anzai T
Int J Cardiol: 14 Dec 2020; 321:113-117 | PMID: 32730825
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Abstract

4D flow cardiac magnetic resonance in children and adults with congenital heart disease: Clinical experience in a high volume center.

Isorni MA, Moisson L, Moussa NB, Monnot S, ... Kara M, Hascoet S
Background
Cardiac magnetic resonance (CMR) imaging with velocity encoding along all three directions of flow, known as 4DFlow CMR, provides both anatomical and functional information. Few data are available on the usefulness of 4DFlow CMR in everyday practice. Here, our objective was to investigate the usefulness of 4DFlow CMR for assessing congenital heart disease (CHD) in everyday practice.
Methods
From 2017 to 2019, consecutive patients who underwent 4DFlow CMR were included prospectively at a single high-volume centre. The parameters recommended by an expert\'s consensus statement for each diagnosis (congenital valvulopathy, septal defect, complex CHD, tetralogy of Fallot, aortic abnormalities) were assessed by two blinded experienced readers. 4DFlow CMRs that provided all recommended parameters were considered successful. Inter-observer and intra-observer agreement were investigated.
Results
We included 187 adults and 60 children covering broad ranges of weight (4.5-142 kg) and age (0.1-67 years). 4DFlow CMR was always the second-line imaging modality, after inconclusive echocardiography, and was successful in 231/247 (91%) patients, with no significant difference between children and adults (54/60, 90%; and 177/187, 95%; respectively; p = .13). Longer time using 4DFlow CMR at our centre was associated with success; in children, older age was also associated with exam success. There was an about 12-month learning curve in children. The success rate was lowest in neonates. Inter-observer and intra-observer agreement were substantial.
Conclusion
Our results suggest that 4DFlow CMR usually provides a comprehensive assessment of CHD in adults and children. A learning curve exists for children and the investigation remains challenging in neonates.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Nov 2020; 320:168-177
Isorni MA, Moisson L, Moussa NB, Monnot S, ... Kara M, Hascoet S
Int J Cardiol: 30 Nov 2020; 320:168-177 | PMID: 32712110
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Abstract

Left ventricular myocardial work in patients with severe aortic stenosis.

Fortuni F, Butcher SC, van der Kley F, Lustosa RP, ... Delgado V, Marsan NA
Background
Left ventricular myocardial work (LVMW) is a novel method to assess LV function utilizing pressure-strain loops that takes into consideration LV afterload. The estimation of LV afterload in severe aortic stenosis (AS) may be challenging and no study so far has investigated LVMW in this setting. The aim of this study was to develop a method to calculate LVMW in severe AS and to analyze its relationship with heart failure (HF) symptoms.
Methods
Indices of LVMW were calculated in 120 patients with severe AS who underwent transcatheter aortic valve replacement and invasive LV and aortic pressure measurements. LV systolic pressure was also derived by adding the mean aortic valve gradient to the aortic systolic pressure. LV global longitudinal strain (GLS) and echocardiography-derived LV systolic pressure were then incorporated to construct pressure-strain loops of the LV.
Results
An excellent correlation was observed between LVMW indices calculated with the invasive and echocardiography-derived LV systolic pressure. Patients in NYHA class III-IV (n=97, 73%) had lower LV GLS, LV global work index (GWI), LV global constructive work (GCW), and right ventricular free-wall strain compared to those in NYHA class I-II. In contrast to LV GLS, LVGWI (OR per-100mmHg%-increase 0.91; 95%CI 0.85-0.98; P=0.012) and LVGCW showed an independent association with NYHA class III-IV HF symptoms.
Conclusion
The calculation of echocardiography-based LVMW indices is feasible in patients with severe AS. In particular, LVGWI and GCW showed an independent association with HF symptoms and may provide additional information on myocardial remodeling and function in severe AS.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 08 Nov 2020; epub ahead of print
Fortuni F, Butcher SC, van der Kley F, Lustosa RP, ... Delgado V, Marsan NA
J Am Soc Echocardiogr: 08 Nov 2020; epub ahead of print | PMID: 33181281
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Impact:
Abstract

Accuracy of left atrial fibrosis detection with cardiac magnetic resonance: correlation of late gadolinium enhancement with endocardial voltage and conduction velocity.

Caixal G, Alarcón F, Althoff TF, Nuñez-Garcia M, ... Guasch E, Mont L
Aims
Myocardial fibrosis is a hallmark of atrial fibrillation (AF) and its characterization could be used to guide ablation procedures. Late gadolinium enhanced-magnetic resonance imaging (LGE-MRI) detects areas of atrial fibrosis. However, its accuracy remains controversial. We aimed to analyse the accuracy of LGE-MRI to identify left atrial (LA) arrhythmogenic substrate by analysing voltage and conduction velocity at the areas of LGE.
Methods and results
Late gadolinium enhanced-magnetic resonance imaging was performed before ablation in 16 patients. Atrial wall intensity was normalized to blood pool and classified as healthy, interstitial fibrosis, and dense scar tissue depending of the resulting image intensity ratio. Bipolar voltage and local conduction velocity were measured in LA with high-density electroanatomic maps recorded in sinus rhythm and subsequently projected into the LGE-MRI. A semi-automatic, point-by-point correlation was made between LGE-MRI and electroanatomical mapping. Mean bipolar voltage and local velocity progressively decreased from healthy to interstitial fibrosis to scar. There was a significant negative correlation between LGE with voltage (r = -0.39, P < 0.001) and conduction velocity (r = -0.25, P < 0.001). In patients showing dilated atria (LA diameter ≥45 mm) the conduction velocity predictive capacity of LGE-MRI was weaker (r = -0.40 ± 0.09 vs. -0.20 ± 0.13, P = 0.02).
Conclusions
Areas with higher LGE show lower voltage and slower conduction in sinus rhythm. The enhancement intensity correlates with bipolar voltage and conduction velocity in a point-by-point analysis. The performance of LGE-MRI in assessing local velocity might be reduced in patients with dilated atria (LA diameter ≥45).

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

Europace: 22 Nov 2020; epub ahead of print
Caixal G, Alarcón F, Althoff TF, Nuñez-Garcia M, ... Guasch E, Mont L
Europace: 22 Nov 2020; epub ahead of print | PMID: 33227129
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Abstract

Transcatheter creation of a Potts shunt with the Occlutech Atrial Flow Regulator: Feasibility in a pig model.

Kang SL, Contreras J, Chaturvedi RR
Background
Creation of a Potts shunt, a connection between the left pulmonary artery (LPA) and descending aorta (DAo), improves functional status and survival in drug-refractory suprasystemic pulmonary arterial hypertension. We investigated a new approach to transcatheter Potts shunt creation in pigs.
Methods and results
In six pigs, a steerable SureFlex sheath was used to optimize the trajectory of perforation from the DAo into LPA using a 0.035″ radiofrequency wire. The combination of a larger perforation, stiffer radiofrequency wire and smooth dilator-to-sheath transition allowed sheath entry into the LPA without requiring an arterio-venous wire circuit. The Occlutech Atrial Flow Regulator (AFR), a double-disc device with a central fenestration, was deployed through this sheath with apposition of the distal disc to the posterior LPA wall and the proximal disc to the anterior DAo wall. The AFR is compliant and crumpling of the central fenestration was resolved by balloon dilation. It was feasible to implant a stent within the fenestration (n = 3). Aortography confirmed a left-to-right shunt through the AFR without contrast extravasation. Autopsy demonstrated anchoring of both discs against the vessel walls, patency of the fenestration and secure placement of the stent with no intra-thoracic bleeding.
Conclusions
In an acute pig model, we have demonstrated the feasibility of creating a transcatheter Potts shunt with a simplified technique using a steerable sheath, a double-disc device with a central fenestration that acts as the shunt channel and optional stenting of the fenestration.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 06 Nov 2020; epub ahead of print
Kang SL, Contreras J, Chaturvedi RR
Int J Cardiol: 06 Nov 2020; epub ahead of print | PMID: 33171168
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Abstract

Predicting the development of adverse cardiac events in patients with hypertrophic cardiomyopathy using machine learning.

Kochav SM, Raita Y, Fifer MA, Takayama H, ... Hasegawa K, Shimada YJ

Background Only a subset of patients with hypertrophic cardiomyopathy (HCM) develop adverse cardiac events - e.g., end-stage heart failure, cardiovascular death. Current risk stratification methods are imperfect, limiting identification of high-risk patients with HCM. Our aim was to improve the prediction of adverse cardiac events in patients with HCM using machine learning methods. Methods We applied modern machine learning methods to a prospective cohort of adults with HCM. The outcome was a composite of death due to heart failure, heart transplant, and sudden death. As the reference model, we constructed logistic regression model using known predictors. We determined 20 predictive characteristics based on random forest classification and a priori knowledge, and developed 4 machine learning models. Results Of 183 patients in the cohort, the mean age was 53 (SD = 17) years and 45% were female. During the median follow-up of 2.2 years (interquartile range, 0.6-3.8), 33 subjects (18%) developed an outcome event, the majority of which (85%) was heart transplant. The predictive accuracy of the reference model was 73% (sensitivity 76%, specificity 72%) while that of the machine learning model was 85% (e.g., sensitivity 88%, specificity 84% with elastic net regression). All 4 machine learning models significantly outperformed the reference model - e.g., area under the receiver-operating-characteristic curve 0.79 with the reference model vs. 0.93 with elastic net regression (p < 0.001). Conclusions Compared with conventional risk stratification, the machine learning models demonstrated a superior ability to predict adverse cardiac events. These modern machine learning methods may enhance identification of high-risk HCM subpopulations.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 08 Nov 2020; epub ahead of print
Kochav SM, Raita Y, Fifer MA, Takayama H, ... Hasegawa K, Shimada YJ
Int J Cardiol: 08 Nov 2020; epub ahead of print | PMID: 33181159
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Abstract

Combined Echocardiographic and Cardiopulmonary Exercise to Assess Determinants of Exercise Limitation in Chronic Obstructive Pulmonary Disease.

Rozenbaum Z, Ben Gal Y, Kapusta L, Hochstadt A, ... Keren G, Topilsky Y
Background
Current methods do not allow a thorough assessment of causes associated with limited exercise capacity in patients with chronic obstructive pulmonary disease (COPD).
Methods
Twenty patients with COPD and 20 matched control subjects were assessed using combined cardiopulmonary and stress echocardiographic testing. Various echocardiographic parameters (left ventricular [LV] volumes, right ventricular [RV] area, ejection fraction, stroke volume, S\', and E/e\' ratio) and ventilatory parameters (peak oxygen consumption [Vo] and A-Vo difference) were measured to evaluate LV and RV function, hemodynamics, and peripheral oxygen extraction (A-VO difference).
Results
Significant differences (both between groups and for group-by-time interaction) were seen in exercise responses (LV volume, RV area, LV volume/RV area ratio, S\', E/e\' ratio, tricuspid regurgitation grade, heart rate, stroke volume, and Vo). The major mechanisms of reduced exercise tolerance in patients with COPD were bowing of the septum to the left in 12 (60%), abnormal increases in E/e\' ratio in 12 (60%), abnormal stroke volume reserve in 16 (80%), low peak A-Vo difference in 10 (50%), chronotropic incompetence in 13 (65%), or a combination of several mechanisms. Patients with COPD and poor exercise tolerance showed attenuated increases in stroke volume, heart rate, and A-Vo difference and exaggerated changes in LV/RV ratio and LV compliance (ratio of LV volume to E/e\' ratio) compared with patients with COPD with good exercise tolerance.
Conclusions
Combined cardiopulmonary and stress echocardiographic testing can be helpful in determining individual mechanisms of exercise intolerance in patients with COPD. In patients with COPD, exercise intolerance is predominantly the result of chronotropic incompetence, limited stroke volume reserve, exercise-induced elevation in left filling pressure, and peripheral factors and not simply obstructive lung function. Limited stroke volume is related to abnormal RV contractile reserve and reduced LV compliance introduced through septal flattening and direct ventricular interaction.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 09 Nov 2020; epub ahead of print
Rozenbaum Z, Ben Gal Y, Kapusta L, Hochstadt A, ... Keren G, Topilsky Y
J Am Soc Echocardiogr: 09 Nov 2020; epub ahead of print | PMID: 33187814
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Abstract

Trans-catheter atrial septal defect closure with the new GORE® cardioform ASD occluder: First European experience.

Santoro G, Castaldi B, Cuman M, Candia AD, ... Pak V, Di Salvo G
Background
This perspective, observational study evaluated safety and efficacy of the GORE® Cardioform ASD Occluder (WL Gore & Associates, Flagstaff, AZ), compliant and potentially innovative prosthesis recently approved for closure of ostium secundum atrial septal defects (ASD).
Methods
Between January and June 2020, 43 unselected patients with -significant ASD were submitted to trans-catheter closure with GORE® Cardioform ASD Occluder at two high-volume Italian Pediatric Cardiology centers. Primary endpoints were procedural success and safety. Secondary endpoints were closure rate and clinical safety at 1-month follow-up.
Results
Patients\' age and weight were 8.2 ± 3.9 years (range 3-21, median 9.9) and 29.6 ± 15.3 kg (range 16-57, median 33.3), respectively. ASD diameter was 16.6 ± 4.5 mm (median 10), resulting in QP/QS of 1.7 ± 0.7 (median 1.6). Seventeen pts. (39.5%) were considered \"surgical\" candidates due to challenging septum morphology, ASD rim deficiency or ASD diameter/patient weight ratio ≥ 1.2. Device placement was successfully achieved in all but one patient (97.7%), in whom it embolized early after deployment, resulting in rescue surgical repair. No cross-over with different devices was recorded. Median procedure and fluoroscopy times were 40 and 6.8 min, respectively. Major adverse events were recorded in 7.0% (3 pts). Complete closure rate was 78.5% at discharge, rising to 92.9% (39/42 pts) at 1 month evaluation, without cardiac or extra-cardiac adverse events. \"Challenging\" procedures were more time-consuming but as effective and safe as the \"simple\" ones.
Conclusions
The GORE® Cardioform ASD Occluder device was highly effective and versatile in closure of ASDs with different anatomy and size, even in challenging settings.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 17 Nov 2020; epub ahead of print
Santoro G, Castaldi B, Cuman M, Candia AD, ... Pak V, Di Salvo G
Int J Cardiol: 17 Nov 2020; epub ahead of print | PMID: 33220363
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Abstract

Cardiac MRI demonstrates compressibility in healthy myocardium but not in myocardium with reduced ejection fraction.

Kumar V, Ryu AJ, Manduca A, Rao C, ... Borlaug BA, Anavekar NS
Background
The professional guidelines assume that the myocardial volume in systole (MVs) is equal to that in diastole (MVd), despite some limited evidence that points to the contrary. The aim of this manuscript is to determine whether this is true in healthy myocardium using gold standard cardiac MRI, as well as transthoracic echocardiography (TTE). The secondary aim is to determine whether there are similar MV changes in patients with heart failure with reduced ejection fraction (HFrEF).
Method
A prospectively derived cohort at Mayo Clinic of 115 adult subjects (mean age 42.8 years, 58% female) with no cardiac risk factors was identified. Cardiac MRI was obtained on all 115 patients, 51 of whom also consented to a TTE. MRI from a retrospectively derived cohort of 50 HFrEF patients was also collected. MVs and MVd was calculated using standard approaches with inclusion of the papillary muscles.
Results
In the healthy population, MRI demonstrated MVs/MVd = 0.87 (SD 0.04) and TTE demonstrated MVs/MVd = 0.79 (SD 0.07), suggesting compressibility (p < 0.0001). In the 51 healthy patients who received both imaging modalities, MVs/MVd was 8.0% higher in MRI than TTE (p < 0.0001), but both modalities had MVs/MVd < 1 (p < 0.0001). A Bland-Altman plot demonstrated that as the mean MVs/MVd increases, the difference in MVs/MVd MRI-TTE declines (r = -0.53, p < 0.0001). However, in HFrEF populations, MVs/MVd = 1.01 (0.03), suggesting myocardial incompressibility.
Conclusion
Contrary to currently accepted standards, healthy myocardium is compressible but HFrEF myocardium is incompressible. The ratio MVs/MVd merits further study in an expanded normal cohort and in disease states.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 31 Dec 2020; 322:278-283
Kumar V, Ryu AJ, Manduca A, Rao C, ... Borlaug BA, Anavekar NS
Int J Cardiol: 31 Dec 2020; 322:278-283 | PMID: 32871188
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Abstract

Early Role of the Atrial Level Communication in Premature Infants with Patent Ductus Arteriosus.

Rios DR, de Freitas Martins F, El-Khuffash A, Weisz DE, Giesinger RE, McNamara PJ
Background
High-volume systemic-to-pulmonary ductus arteriosus shunts in premature infants are associated with adverse neonatal outcomes. The role of an atrial communication (AC) in modulating effects of a presumed hemodynamically significant patent ductus arteriosus (hsPDA) is poorly studied. The objective of this study was to characterize the relationship between early AC and echocardiography indices of PDA shunt volume and clinical neonatal outcomes.
Methods
We performed a retrospective review of preterm infants (born <32 weeks\' gestation) with echocardiography in the first postnatal week. We divided the cohort into four groups based on presence of a presumed hsPDA (≥1.5 mm vs. <1.5 mm) and AC size (≤1 mm vs. >1 mm) then compared echocardiography measures of PDA shunt volume. We also compared clinical outcomes, including chronic lung disease (CLD) and intraventricular hemorrhage (IVH) between all 4 groups.
Results
A total of 199 preterm infants (mean birthweight and gestational age of 928 ± 632 grams and 26.6 ± 1.5 weeks, respectively) were identified; 159 infants had PDA ≥1.5 mm, of whom 52 had AC ≤1 mm and 107 had AC >1 mm. The remaining 40 infants had PDA <1.5 mm, of whom 23 had AC ≤1 mm and 17 had AC >1 mm. Infants with PDA ≥1.5 mm and AC >1 mm had higher pulmonary vein D wave velocity (p<0.05), higher left ventricular output (p<0.005), higher PDA score (p<0.001), and increased rate of reversed diastolic flow in the descending aorta (p<0.001), celiac artery (p<0.001), and middle cerebral artery (p<0.001) than infants with either PDA <1.5mm or PDA ≥1.5 mm and AC ≤1 mm. There was no difference in incidence of IVH, but infants with PDA ≥1.5 mm and AC >1 mm had higher risk of composite outcome of CLD or death prior to hospital discharge (p<0.05).
Conclusion
Echocardiography evidence of AC >1 mm in patients with a PDA ≥1.5 mm, during the first postnatal week, may be a marker of a more pathologic hsPDA in premature infants. Future investigations should evaluate if early identification and treatment of patients with both high-volume PDA and larger atrial level communications may help mitigate adverse outcomes, such as CLD or death, in this high-risk patient population.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 19 Nov 2020; epub ahead of print
Rios DR, de Freitas Martins F, El-Khuffash A, Weisz DE, Giesinger RE, McNamara PJ
J Am Soc Echocardiogr: 19 Nov 2020; epub ahead of print | PMID: 33227390
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Abstract

Left Atrial Strain Is the Best Predictor of Adverse Cardiovascular Outcomes in Patients with Chronic Kidney Disease.

Gan GCH, Kadappu KK, Bhat A, Fernandez F, ... Eshoo S, Thomas L
Background
Patients with chronic kidney disease (CKD) are at increased risk of adverse cardiovascular events, which is underestimated by traditional risk stratification algorithms. We sought to determine clinical and echocardiographic predictors of adverse outcomes in CKD patients.
Methods
Two hundred forty-three prospectively recruited stage 3/4 CKD patients (male, 63%; mean age, 59.2 ± 14.4 years) without previous cardiac disease made up the study cohort. All participants underwent a transthoracic echocardiogram, with left ventricular (LV) and left atrial (LA) strain analysis. Participants were followed for 3.9 ± 2.7 years for the primary end point of cardiovascular death and major adverse cardiovascular event (MACE). The secondary end point was the composite of all-cause death and MACE.
Results
Fifty-four patients met the primary end point, and 65 the secondary end point. On log-rank tests, older age, diabetes mellitus, anemia, greater LV mass, reduced LV global longitudinal strain, larger indexed LA volume, higher E/e\' ratio, and reduced LA reservoir strain (LASr; P < .01 for all) were independent predictors of cardiovascular death and MACE. On multivariable regression analysis of univariate predictors, LASr (P < .01) was the only independent predictor for the primary end point as well as for the secondary end point. Receiver operating characteristic curve analysis showed LASr was a stronger predictor of adverse events (area under the curve [AUC] = 0.84) compared to the Framingham (AUC = 0.58) and Atherosclerotic Cardiovascular Disease (AUC = 0.59) risk scores.
Conclusions
LASr is an independent predictor of cardiovascular death and MACE in CKD patients, superior to clinical risk scores, LV parameters, and LA volume.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 18 Nov 2020; epub ahead of print
Gan GCH, Kadappu KK, Bhat A, Fernandez F, ... Eshoo S, Thomas L
J Am Soc Echocardiogr: 18 Nov 2020; epub ahead of print | PMID: 33223356
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Abstract

Basal segmental longitudinal strain: a marker of subclinical myocardial involvement in Anderson-Fabry disease.

Zada M, Lo Q, Boyd AC, Bradley S, ... Tchan MC, Thomas L
Objective
Cardiac involvement in Anderson-Fabry disease (AFD) is associated with increased LV wall thickness. We evaluated if two-dimensional (2D) global and regional strain in AFD patients can identify early myocardial involvement (when LV wall thickness and function is normal). We additionally evaluated the association of altered strain with adverse cardiovascular events.
Methods
A retrospective cross-sectional study of 43 AFD patients, prior to enzyme replacement therapy (mean age 44 years ±12, 58.1% male), compared to age and gender matched healthy controls. Mean follow-up of AFD patients for major adverse cardiovascular events (MACE) was 82 months.
Results
LV ejection fraction was similar between groups (AFD vs controls: 61% ±8 vs 61%±6, p=0.89). However, global longitudinal strain (GLS) was impaired in AFD patients compared to controls (-16.5% ±3.8 vs -20.2% ±1.7, p<0.001), with greater impairment in AFD patients with increased LV wall thickness (-15.4%±3.9 vs -18.7% ±2.3, p<0.006). Additionally, longitudinal strain (LS) was most impaired in the basal segments in AFD patients (-14.8 ± 3.7 vs -20.3 ± 1.1; p<0.001). MACE occurred in 19/43 (4 females; 15 males) and Kaplan-Meyer analysis demonstrated that MACE was associated with impaired basal LS.
Conclusions
In AFD patients, altered basal LS is present even in AFD patients with normal LV wall thickness, and is associated with MACE. Therefore, basal LS should be considered when screening for cardiac involvement in AFD, particularly in female AFD patients with normal LV wall thickness.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 22 Nov 2020; epub ahead of print
Zada M, Lo Q, Boyd AC, Bradley S, ... Tchan MC, Thomas L
J Am Soc Echocardiogr: 22 Nov 2020; epub ahead of print | PMID: 33242609
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Abstract

Safety and cost-effectiveness of same-day complex left atrial ablation.

He H, Datla S, Weight N, Raza S, ... Hayat S, Osman F
Background
Catheter ablation for complex left-atrial arrhythmia is increasing worldwide with many centres admitting patients overnight. Same-day procedures using conscious sedation carry significant benefits to patients/healthcare providers but data are limited. We evaluated the safety and cost-effectiveness of same-day complex left-atrial arrhythmia ablation.
Method
Multi-centre retrospective cohort study of all consecutive complex elective left-atrial ablation procedures performed between January 2011 and December 2019. Data were collected on planned same-day discharge versus overnight stay, baseline parameters, procedure details/success, ablation technology, post-operative complications, unplanned overnight admissions/outcomes at 4-months and mortality up to April 2020. A cost analysis of potential savings was also performed.
Results
A total of 967 consecutive patients underwent complex left-ablation using radiofrequency (point-by-point ablation aided by 3D-mapping or PVAC catheter ablation with fluoroscopic screening) or cryoballoon-ablation (mean age: 60.9 ± 11.6 years, range 23-83 yrs., 572 [59%] females). The majority of patients had isolation of pulmonary veins alone (n = 846, 87%) and most using conscious-sedation alone (n = 921, 95%). Of the total cohort, 414 (43%) had planned same-day procedure with 35 (8%) admitted overnight due to major (n = 5) or minor (n = 30) complications. Overall acute procedural success-rate was 96% (n = 932). Complications in planned overnight-stay/same-day cohorts were low. At 4-month follow-up there were 62 (6.4%) readmissions (femoral haematomas, palpitation, other reasons); there were 3 deaths at mean follow-up of 42.0 ± 27.6 months, none related to the procedure. Overnight stay costs £350; the same-day ablation policy over this period would have saved £310,450.
Conclusions
Same-day complex left-atrial catheter ablation using conscious sedation is safe and cost-effective with significant benefits for patients and healthcare providers. This is especially important in the current financial climate and Covid-19 pandemic.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 31 Dec 2020; 322:170-174
He H, Datla S, Weight N, Raza S, ... Hayat S, Osman F
Int J Cardiol: 31 Dec 2020; 322:170-174 | PMID: 33002522
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Abstract

Right ventricular dysfunction in critically ill COVID-19 ARDS.

Bleakley C, Singh S, Garfield B, Morosin M, ... Patel BV, Price S
Aims
Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS).
Methods
Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data.
Results
Ninety patients (25.6% female), mean age 52.0 ± 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0-81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3-93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0-33.9), RVS\' (11.9%, 95% CI 6.6-20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6-49.0). RV VTI correlated strongly with RV FAC (p ≤0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p < 0.01), as well as RVEDAi (p < 0.01), and RVESAi (p < 0.01), and was associated with P/F ratio (p 0.026), PEEP (p 0.025), and ALT (p 0.028).
Conclusions
Severe COVID-19 ARDS is associated with a specific phenotype of RV radial impairment with sparing of longitudinal function. Clinicians should avoid interpretation of RV health purely on long-axis parameters in these patients. RV-PA coupling potentially provides important additional information above standard measures of RV performance in this cohort.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 22 Nov 2020; epub ahead of print
Bleakley C, Singh S, Garfield B, Morosin M, ... Patel BV, Price S
Int J Cardiol: 22 Nov 2020; epub ahead of print | PMID: 33242508
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Abstract

Effect of Intermittent High Mechanical Index Impulses on Left Ventricular Strain.

Albulushi A, Olson J, Xie F, Qian L, ... Aboeata A, Porter T
Background
Intermittent high mechanical index (MI) impulses from a transthoracic ultrasound transducer are recommended for regional wall motion (RWM) analysis and assessment of myocardial perfusion following an intravenous administration of ultrasound enhancing agents (UEAs). High MI impulses (>1.0) applied in this setting have also been shown to increase microvascular blood flow via a purinergic signaling pathway, but their effects on left ventricular (LV) myocardial function are unknown. Therefore, we investigated the effect of transthoracic intermittent high MI (IH MI) impulses during an intravenous UEA infusion in patients with normal and abnormal resting systolic function.
Methods
Fifty patients referred for echocardiography to evaluate LV systolic function during a continuous infusion of UEAs (Definity 3% infusion), were prospectively assigned to: Group 1: low MI (<0.2) imaging alone; or Group 2: low MI (<0.2) imaging with IH MI impulses (five frames; 1.8 MHz, 1.0-1.1 MI) applied at least two times in each apical window to clear myocardial contrast. Global (GLS) strain measurements were obtained at baseline prior to UEA administration and at five minute intervals up to 10 minutes after infusion completion.
Results
There were no differences between groups with respect to age, gender, resting GLS, biplane left ventricular ejection fraction (LVEF), or cardiac risk factors. Resting GLS in group 1 was -15.5 + 5.2% before to -15.5 + 5.4% at 10 minutes after UEA infusion. In comparison, GLS increased in Group II (-15.3+5.0 before and -16.8 + 4.8 % at 10 minutes; p<0.00001). Improvements in GLS were seen in patients with normal and abnormal systolic function. Regional analysis demonstrated the increase in strain in the abnormal LVEF patients was primarily in the apical segments (-12.0+2.7% before to -13.4+3.4% at 10 minutes after IH MI; p=0.001).
Conclusions
High mechanical index impulses during a commercially available contrast infusion can improve left ventricular systolic function, and may have therapeutic effect in patients with left ventricular dysfunction.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 26 Nov 2020; epub ahead of print
Albulushi A, Olson J, Xie F, Qian L, ... Aboeata A, Porter T
J Am Soc Echocardiogr: 26 Nov 2020; epub ahead of print | PMID: 33253816
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Abstract

Association of left ventricular volume in predicting clinical outcomes in patients with aortic regurgitation.

Anand V, Yang L, Luis SA, Padang R, ... Nishimura RA, Pellikka PA
Background
Aortic regurgitation (AR) is a common valvular lesion associated with increased mortality once the left ventricle (LV) enlarges significantly or develops systolic dysfunction (EF <50%). Valve guidelines recommend aortic valve repair or replacement (AVR) for LV linear end-systolic dimension (LVESD) ≥ 50 mm or end-diastolic dimension ≥ 65 mm. However, chamber quantification guidelines recommend using LV volume for LV size determination as linear measurements may not accurately reflect LV remodeling. We sought to evaluate the correlation of LV volumes with linear dimensions, inter-observer variability in estimation of volumes, and association of volumes with outcomes in patients with AR.
Methods
We retrospectively analyzed 1100 consecutive patients with chronic moderate-severe and severe AR by echocardiography between 2004 and 2019. Modified Simpson\'s disc summation method was used for LV volume estimation. The primary outcome was all-cause mortality; secondary outcome was mortality censored at AVR.
Results
Patients\' age was 60 ± 17 years and 198 (18%) were women. Volumes were measured by biplane method in 939 (85%) patients and monoplane in 161 (15%); end-systolic volume was normal in 169 (11%). Correlations between volumes and linear dimensions were 0.5 for end-diastolic and 0.6 for end-systolic. At median follow up of 5.4 (2.4-10.0) years, 216 patients died and 539 underwent AVR. Indexed LV end-systolic volume (iLVESV) and iLVESD were both associated with mortality and symptoms, but association of iLVESV was stronger. iLVESV, age, male gender, Charlson comorbidity index, NYHA class III-IV, and time dependent AVR were independently associated with all-cause mortality. The inter-observer variability in estimation of LV volumes in 200 patients included intra-class coefficient 0.94 (0.92-0.95) for end-diastolic and 0.88 (0.78-0.93) for end-systolic volume. Patients with iLVESV≥45ml/m had lower survival and higher prevalence of symptoms than those with volumes <45 ml/m.
Conclusion
Echocardiographic LV volume assessment had good reproducibility in patients with moderate-severe and severe AR. The correlation between linear dimensions and volumes was limited. Both iLVESV and iLVESD were associated with worse outcomes, but association of iLVESV was stronger. iLVESV ≥45ml/m was associated with worse outcomes.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 26 Nov 2020; epub ahead of print
Anand V, Yang L, Luis SA, Padang R, ... Nishimura RA, Pellikka PA
J Am Soc Echocardiogr: 26 Nov 2020; epub ahead of print | PMID: 33253815
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Abstract

Excess mortality associated with progression rate in asymptomatic aortic valve stenosis.

Benfari G, Nistri S, Marin F, Cerrito LF, ... Rossi A, Ribichini FL
Background
Aortic valve stenosis (AS) is a progressive condition characterized by gradual calcification of the aortic cusps. Progression-rate evaluated by echocardiography has been associated with survival. However, data from routine practice, covering the whole spectrum of AS severity and the rate of symptoms onset are sparse. We aimed to assess the outcome under medical management related to the disease progression in asymptomatic patients with a wide range of AS severity.
Methods
We retrospectively included 229 consecutive asymptomatic patients (77±10 years, 55% males) with AS, preserved ejection-fraction (LVEF), and ≥2 echocardiographic examinations performed from 2004 to 2014. Median time between the two echocardiograms was 24[15-46] months. Patients were identified as rapid-progressors if the annualized difference in peak-aortic-velocity (Vmax) between two echocardiographic examinations was ≥ 0.3 m/sec/year; others were labeled as slow-progressors. Primary-endpoint was mortality during medical follow-up (censoring on aortic-valve-interventions). Secondary-endpoint was overall mortality.
Results
Rapid-progressor patients were 67/229 (29%), and this feature was not associated with patients\' baseline characteristics. During 5.8 [3.4-8.3] years of follow-up from the first echocardiogram, 102(45%) patients died, 86(84%) during medical follow-up. Rapid-progression rate predicted excess-mortality (vs. slow-progression rate) after adjustment for age, sex, symptoms, baseline-LVEF, and baseline-aortic valve area (HR:2.50 [1.48-4.21], p=0.0006) and after adjusting for Vmax and LVEF obtained at the last echo (HR:2.07 [1.25-3.46], p=0.005). Among patients with baseline Vmax <4 m/s (non-severe AS), rapid-progression rate associated with higher 5-year mortality vs. slow-progression (57% vs 22%, p<0.0001 under medical management and 44% vs 18%, p=0.005 overall). Outcomes were comparable between non-severe AS rapid progressors and baseline severe-AS. Progression-rate showed incremental prognostic value at ROC analysis vs. AS severity. Of note, among slow-progressors, 11 patients (5%) presented with high rate of symptom development and poor outcome related to ventricular dysfunction or other advanced AS stage features.
Conclusion
The progression-rate is an individual, almost unpredictable, feature of AS patients. Rapid-progression is an incremental marker of excess mortality in asymptomatic AS patients, independently from clinical and hemodynamic characteristics. Rapid progression-rate may identify patients with non-severe AS at higher risk of events.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 26 Nov 2020; epub ahead of print
Benfari G, Nistri S, Marin F, Cerrito LF, ... Rossi A, Ribichini FL
J Am Soc Echocardiogr: 26 Nov 2020; epub ahead of print | PMID: 33253813
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Impact:
Abstract

Clinical and gated SPECT MPI parameters associated with super-response to cardiac resynchronization therapy.

Mesquita CT, Peix A, de Amorim Fernandes F, Giubbini R, ... Paez D, Garcia EV
Purpose
We sought to evaluate the behavior of cardiac mechanical synchrony as measured by phase SD (PSD) derived from gated MPI SPECT (gSPECT) in patients with super-response after CRT and to evaluate the clinical and imaging characteristics associated with super-response.
Methods
158 subjects were evaluated with gSPECT before and 6 months after CRT. Patients with an improvement of LVEF > 15% and NYHA class I/II or reduction in LV end-systolic volume > 30% and NYHA class I/II were labeled as super-responders (SR).
Results
34 patients were classified as super-responders (22%) and had lower PSD (32° ± 17°) at 6 months after CRT compared to responders (45° ± 24°) and non-responders 46° ± 28° (P = .02 for both comparisons). Regression analysis identified predictors independently associated with super-response to CRT: absence of previous history of CAD (odds ratio 18.7; P = .002), absence of diabetes mellitus (odds ratio 13; P = .03), and history of hypertension (odds ratio .2; P = .01).
Conclusion
LV dyssynchrony after CRT implantation, but not at baseline, was significantly better among super-responders compared to non-super-responders. The absence of diabetes, absence of CAD, and history of hypertension were independently associated with super-response after CRT.



J Nucl Cardiol: 04 Nov 2020; epub ahead of print
Mesquita CT, Peix A, de Amorim Fernandes F, Giubbini R, ... Paez D, Garcia EV
J Nucl Cardiol: 04 Nov 2020; epub ahead of print | PMID: 33152098
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Impact:
Abstract

Non-traditional factors affecting referral for coronary angiography following SPECT myocardial perfusion imaging.

Gowdar S, Hussain N, Ahlberg AW, Elsadany M, ... Silverman D, Duvall WL
Background
The use of myocardial perfusion imaging (MPI) in the management of coronary artery disease (CAD) is well established. Although prior studies have shown disparities in the use of invasive angiography in patients with acute MI, data on factors affecting referral to angiography post-MPI are lacking. We sought to evaluate the primary determinants of referral to invasive angiography post-MPI and specifically assess the role of non-traditional non-clinical factors such as race/ethnicity, socioeconomic factors, insurance status, and marital status.
Methods
All patients without known CAD who underwent stress SPECT MPI over 15 years were reviewed and the performance of coronary angiography within 90 days of their MPI was recorded. Multiple factors were analyzed for an association with referral to angiography, including exercise and MPI results, baseline demographics, traditional cardiac risk factors, and non-traditional factors such as ethnicity, insurance, marital and socioeconomic status. In a secondary analysis, these factors were assessed with regard to abnormal MPI results.
Results
Out of 27,895 total patients, 2,150 (7.7%) underwent invasive coronary angiography. On multivariate analysis, inpatient location, positive ECG response, and abnormal MPI results were the strongest predictors of angiography. Non-traditional factors such as race/ethnicity and insurance status had a significant association with referral to angiography with Caucasians (OR 1.42, 95% CI 1.18-1.71, P < .0001) and those with private insurance (OR 1.35, 95% CI 1.13-1.62, P = .001) or Medicare (OR 1.30, 95% CI 1.08-1.56, P = .006) having higher rates of angiography despite controlling for traditional risk factors and test results.
Conclusion
Our study results indicate that non-traditional factors such as race/ethnicity and insurance status influence patient management decisions and impact the performance of downstream cardiac invasive testing after stress MPI. Higher rates of angiography in Caucasians, privately insured and Medicare patients were seen despite controlling for traditional risk factors and abnormal test results. Further research is needed to better understand these disparities, especially in the current healthcare environment.



J Nucl Cardiol: 04 Nov 2020; epub ahead of print
Gowdar S, Hussain N, Ahlberg AW, Elsadany M, ... Silverman D, Duvall WL
J Nucl Cardiol: 04 Nov 2020; epub ahead of print | PMID: 33152097
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Impact:
Abstract

Automated abstraction of myocardial perfusion imaging reports using natural language processing.

Zheng C, Sun BC, Wu YL, Ferencik M, ... Musigdilok VV, Sharp AL
Background
Findings and interpretations of myocardial perfusion imaging (MPI) studies are documented in free-text MPI reports. MPI results are essential for research, but manual review is prohibitively time consuming. This study aimed to develop and validate an automated method to abstract MPI reports.
Methods
We developed a natural language processing (NLP) algorithm to abstract MPI reports. Randomly selected reports were double-blindly reviewed by two cardiologists to validate the NLP algorithm. Secondary analyses were performed to describe patient outcomes based on abstracted-MPI results on 16,957 MPI tests from adult patients evaluated for suspected ACS.
Results
The NLP algorithm achieved high sensitivity (96.7%) and specificity (98.9%) on the MPI categorical results and had a similar degree of agreement compared to the physician reviewers. Patients with abnormal MPI results had higher rates of 30-day acute myocardial infarction or death compared to patients with normal results. We identified issues related to the quality of the reports that not only affect communication with referring physicians but also challenges for automated abstraction.
Conclusion
NLP is an accurate and efficient strategy to abstract results from the free-text MPI reports. Our findings will facilitate future research to understand the benefits of MPI studies but requires validation in other settings.



J Nucl Cardiol: 04 Nov 2020; epub ahead of print
Zheng C, Sun BC, Wu YL, Ferencik M, ... Musigdilok VV, Sharp AL
J Nucl Cardiol: 04 Nov 2020; epub ahead of print | PMID: 33155169
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Impact:
Abstract

Gating failure can result in underestimation of cardiac function in myocardial perfusion scintigraphy.

Villagran Asiares A, Yakushev I, Nekolla SG

Here, we present a case with a pacemaker due to an atrioventricular (AV) block 2 Mobitz type, in whom a gating failure resulted in a relevant underestimation of cardiac function in myocardial perfusion scintigraphy. A set of quality control steps for gating errors is proposed.



J Nucl Cardiol: 10 Nov 2020; epub ahead of print
Villagran Asiares A, Yakushev I, Nekolla SG
J Nucl Cardiol: 10 Nov 2020; epub ahead of print | PMID: 33175303
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Impact:
Abstract

The \"fixed\" SPECT MPI defect: Where are we and where should we be going?

Gewirtz H

This brief review focuses on reasons why myocardial perfusion imaging (MPI) SPECT defects may appear \"fixed\" (rest vs stress). A combination of technical and physiology factors are responsible in most cases and are discussed. Perhaps the major reason defects will appear fixed is that there is no absolute quantitative measurement of myocardial blood flow (MBF, rest and stress) with which to assess the magnitude and potential direction of change in the defect vs reference zone with stress. Cardiac PET MPI provides absolute measurements of MBF required to understand the clinical significance of the SPECT \"fixed\" defect and are highlighted. Emphasis is given to use of the actual MBF measurements though indexing stress MBF to that of truly normal subjects (RFR or FFR) will prove useful in recognition of multi-vessel CAD. The availability of 18F flurpiridaz for clinical use is likely to encourage more widespread adoption of cardiac PET MPI for evaluation of patients with known or suspected CAD.



J Nucl Cardiol: 10 Nov 2020; epub ahead of print
Gewirtz H
J Nucl Cardiol: 10 Nov 2020; epub ahead of print | PMID: 33175302
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Impact:
Abstract

Detecting native and bioprosthetic aortic valve disease using F-sodium fluoride: Clinical implications.

Fletcher AJ, Dweck MR

Calcific aortic valve disease is the most common valvular disease and confers significant morbidity and mortality. There are currently no medical therapies that successfully halt or reverse the disease progression, making surgical replacement the only treatment currently available. The majority of patients will receive a bioprosthetic valve, which themselves are prone to degeneration and may also need replaced, adding to the already substantial healthcare burden of aortic stenosis. Echocardiography and computed tomography can identify late-stage manifestations of the disease process affecting native and bioprosthetic aortic valves but cannot detect or quantify early molecular changes. F-fluoride positron emission tomography, on the other hand, can non-invasively and sensitively assess disease activity in the valves. The current review outlines the pivotal role this novel molecular imaging technique has played in improving our understanding of native and bioprosthetic aortic valve disease, as well as providing insights into its feasibility as an important future research and clinical tool.



J Nucl Cardiol: 10 Nov 2020; epub ahead of print
Fletcher AJ, Dweck MR
J Nucl Cardiol: 10 Nov 2020; epub ahead of print | PMID: 33175301
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Impact:
Abstract

Multimodality molecular imaging: Gaining insights into the mechanisms linking chronic stress to cardiovascular disease.

Osborne MT, Abohashem S, Zureigat H, Abbasi TA, Tawakol A

Positron emission tomography (PET) imaging can yield unique mechanistic insights into the pathophysiology of atherosclerosis. F-fluorodeoxyglucose (F-FDG), a radiolabeled glucose analog, is retained by cells in proportion to their glycolytic activity. While F-FDG accumulates within several cell types in the arterial wall, its retention correlates with macrophage content, providing an index of arterial inflammation (ArtI) which predicts subsequent cardiovascular disease (CVD) events. Furthermore, F-FDG-PET imaging allows the simultaneous assessment of metabolic activity in several tissues (e.g., brain, bone marrow) and is performed in conjunction with cross-sectional imaging that enables multi-organ structural assessments. Accordingly, F-FDG-PET/computed tomography (CT) imaging facilitates evaluation of disease pathways that span multiple organ systems. Within this paradigm, F-FDG-PET/CT imaging has been implemented to study the mechanism linking chronic stress to CVD. To evaluate this, stress-associated neural activity can be quantified (as metabolic activity of the amygdala (AmygA)), while leukopoietic activity, ArtI, and coronary plaque burden are assessed concurrently. Such simultaneous quantification of tissue structures and activities enables the evaluation of multi-organ pathways with the aid of mediation analysis. Using this approach, multi-system F-FDG-PET/CT imaging studies have demonstrated that chronically heightened stress-associated neurobiological activity promotes leukopoietic activity and systemic inflammation. This in turn fuels more ArtI and greater non-calcified coronary plaque burden, which result in more CVD events. Subsequent studies have revealed that common stressors, such as chronic noise exposure and income disparities, drive the front end of this pathway to increase CVD risk. Hence, multi-tissue multimodality imaging serves as a powerful tool to uncover complex disease mechanisms.



J Nucl Cardiol: 16 Nov 2020; epub ahead of print
Osborne MT, Abohashem S, Zureigat H, Abbasi TA, Tawakol A
J Nucl Cardiol: 16 Nov 2020; epub ahead of print | PMID: 33205328
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Impact:
Abstract

Single-photon cardiac imaging in patients with cardiac implantable electrical devices.

Valzania C, Bonfiglioli R, Fallani F, Martignani C, ... Fanti S, Galiè N

Nuclear imaging techniques like single-photon emission computed tomography (SPECT) and radionuclide angiography have wide applications in patients receiving a cardiac implantable electrical device (CIED), who cannot usually undergo cardiac magnetic resonance. Our aim was to provide an update of single-photon imaging clinical applications, with a specific focus on CIED recipients. SPECT imaging is commonly used in CIED patients to assess myocardial perfusion, but it can also be used to evaluate myocardial viability, which is an important predictor of LV function improvement by cardiac resynchronization therapy (CRT). Radionuclide angiography has shown higher temporal resolution and reproducibility than SPECT in the evaluation of cardiac function and dyssynchrony. Left ventricular dyssynchrony as assessed by radionuclide angiography with phase analysis may be reliably used for CRT patient selection and evaluation of CRT response. SPECT imaging with meta-iodo-benzyl-guanidine allows for cardiac sympathetic innervation examination, which may be used for prognostic stratification of heart failure patients and prediction of ventricular tachyarrhythmias. Finally, promising results in CIED infection diagnosis have been shown by SPECT with radiolabeled autologous white blood cells.



J Nucl Cardiol: 24 Nov 2020; epub ahead of print
Valzania C, Bonfiglioli R, Fallani F, Martignani C, ... Fanti S, Galiè N
J Nucl Cardiol: 24 Nov 2020; epub ahead of print | PMID: 33241474
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Impact:
Abstract

The application of molecular imaging to advance translational research in chronic inflammation.

Zhou W, Dey A, Manyak G, Teklu M, ... Teague H, Mehta NN

Over the past several decades, molecular imaging techniques to assess cellular processes in vivo have been integral in advancing our understanding of disease pathogenesis. F-fluorodeoxyglucose (18-FDG) positron emission tomography (PET) imaging in particular has shaped the field of atherosclerosis research by highlighting the importance of underlying inflammatory processes that are responsible for driving disease progression. The ability to assess physiology using molecular imaging, combining it with anatomic delineation using cardiac coronary angiography (CCTA) and magnetic resonance imaging (MRI) and lab-based techniques, provides a powerful combination to advance both research and ultimately clinical care. In this review, we demonstrate how molecular imaging studies, specifically using 18-FDG PET, have revealed that early vascular disease is a systemic process with multiple, concurrent biological mechanisms using inflammatory diseases as a basis to understand early atherosclerotic mechanisms in humans.



J Nucl Cardiol: 25 Nov 2020; epub ahead of print
Zhou W, Dey A, Manyak G, Teklu M, ... Teague H, Mehta NN
J Nucl Cardiol: 25 Nov 2020; epub ahead of print | PMID: 33244675
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Impact:
Abstract

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

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

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

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

Impact of Pulmonary Ridge Coverage after Left Atrial Appendage Occlusion.

Freixa X, Cepas-Guillen P, Flores-Umanzor E, Regueiro A, ... Sitges M, Sabaté M
Aims
To evaluate the impact of pulmonary ridge (PR) coverage on both clinical and imaging follow-up outcomes in patients undergoing left atrial appendage occlusion (LAAO).
Methods and results
The study included consecutive patients with non-valvular atrial fibrillation who underwent LAAO with disc and lobe devices. Patients were classified in two groups according to the PR coverage. A total of 147 patients were included. Among them, PR was covered in 109 (74%) and uncovered in 38 (26%). Successful implantation was achieved in 98.6%. No differences in procedural outcomes were observed among groups. The rate of procedural major adverse events was 3% (only major bleedings and/or vascular access complications). No device embolization, cardiac tamponade or in-hospital mortality was observed. After a mean follow-up of 1.77±2.2 years, the annualized ischemic stroke and major bleeding rate was 1.3%/year and 6.5%/year respectively without differences among groups. At follow-up, patients with a covered PR presented a lower incidence of device related thrombosis (DRT) (1%) than those with uncovered PR (27%); p<0.001. In multivariable analysis, the presence of PR coverage emerged as an independent predictor of DRT.
Conclusions
Pulmonary ridge coverage was associated with a lower incidence of DRT after LAAO. Procedural and follow-up clinical outcomes did not differ among covered-PR and uncovered-PR patients.



EuroIntervention: 09 Nov 2020; epub ahead of print
Freixa X, Cepas-Guillen P, Flores-Umanzor E, Regueiro A, ... Sitges M, Sabaté M
EuroIntervention: 09 Nov 2020; epub ahead of print | PMID: 33164895
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Impact:
Abstract

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

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

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

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

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

SCMR Position Paper (2020) on clinical indications for cardiovascular magnetic resonance.

Leiner T, Bogaert J, Friedrich MG, Mohiaddin R, ... Raman SV, Pennell DJ

The Society for Cardiovascular Magnetic Resonance (SCMR) last published its comprehensive expert panel report of clinical indications for CMR in 2004. This new Consensus Panel report brings those indications up to date for 2020 and includes the very substantial increase in scanning techniques, clinical applicability and adoption of CMR worldwide. We have used a nearly identical grading system for indications as in 2004 to ensure comparability with the previous report but have added the presence of randomized controlled trials as evidence for level 1 indications. In addition to the text, tables of the consensus indication levels are included for rapid assimilation and illustrative figures of some key techniques are provided.



J Cardiovasc Magn Reson: 08 Nov 2020; 22:76
Leiner T, Bogaert J, Friedrich MG, Mohiaddin R, ... Raman SV, Pennell DJ
J Cardiovasc Magn Reson: 08 Nov 2020; 22:76 | PMID: 33161900
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Impact:
Abstract

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

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

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

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

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

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

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

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

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

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

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

Eur Heart J Cardiovasc Imaging: 08 Nov 2020; epub ahead of print
Bularga A, Saraste A, Fontes-Carvalho R, Holte E, ... Haugaa KH, Dweck MR
Eur Heart J Cardiovasc Imaging: 08 Nov 2020; epub ahead of print | PMID: 33165600
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Impact:
Abstract

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

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

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

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

The impact of uncorrected mild aortic insufficiency at the time of left ventricular assist device implantation.

Tanaka Y, Nakajima T, Fischer I, Wan F, ... Masood MF, Itoh A
Objective
The study objective was to investigate the progression of uncorrected mild aortic insufficiency and its impact on survival and functional status after left ventricular assist device implantation.
Methods
We retrospectively reviewed 694 consecutive patients who underwent implantation of a continuous-flow left ventricular assist device between January 2006 and March 2018. Pre-left ventricular assist device transthoracic echocardiography identified 111 patients with mild aortic insufficiency and 493 patients with trace or no aortic insufficiency. To adjust for differences in preoperative factors, propensity score matching was used, resulting in 101 matched patients in each of the mild aortic insufficiency and no aortic insufficiency groups.
Results
Although both groups showed similar survival (P = .58), the mild aortic insufficiency group experienced higher incidence of readmission caused by heart failure (hazard ratio, 2.62; 95% confidence interval, 1.42-4.69; P < .01). By using the mixed effect model, pre-left ventricular assist device mild aortic insufficiency was a significant risk factor for both moderate or greater aortic insufficiency and worsening New York Heart Association functional status (P < .01).
Conclusions
Patients with uncorrected mild aortic insufficiency had a higher risk of progression to moderate or greater aortic insufficiency after left ventricular assist device implantation with worse functional status and higher incidence of readmission caused by heart failure compared with patients without aortic insufficiency. Further investigations into the safety and efficacy of concomitant aortic valve procedures for mild aortic insufficiency at the time of left ventricular assist device implant are warranted to improve patients\' quality of life, considering the longer left ventricular assist device use as destination therapy and bridge to transplant with the new US heart allocation system.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 29 Nov 2020; 160:1490-1500.e3
Tanaka Y, Nakajima T, Fischer I, Wan F, ... Masood MF, Itoh A
J Thorac Cardiovasc Surg: 29 Nov 2020; 160:1490-1500.e3 | PMID: 32998831
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Abstract

Heterogenous Distribution of Risk for Cardiovascular Disease Events in Patients With Stable Ischemic Heart Disease.

Mortensen MB, Steffensen FH, Bøtker HE, Jensen JM, ... Blaha MJ, Nørgaard BL
Objectives
The authors sought to assess the distribution of 5-year risk of cardiovascular disease (CVD) events (myocardial infarction, revascularizations, ischemic stroke) and death among symptomatic patients with varying degrees of coronary artery disease (CAD) ascertained from computed tomography angiography (CTA).
Background
CTA is used increasingly as the first-line test for evaluating patients with symptoms suggestive of CAD. This creates the daily clinical challenge of best using the information available from CTA to guide appropriate downstream allocation of preventive treatments.
Methods
Among 21,275 patients from the Western Denmark Heart Registry, the authors developed a model predicting 5-year risk for CVD and death based on traditional risk factors and CAD severity. Only events occurring >90 days after CTA were included.
Results
During a median follow-up of 4.2 years, 1,295 CVD events and deaths occurred. The median 5-year risk for events was 4% (interquartile range: 3% to 8%), and ranged from <5% to >50% in individual patients. The degree of CAD severity was the strongest risk factor; however, traditional risk factors also contributed significantly to risk. Thus, risk distributions in patients with varying degree of CAD overlapped considerably, and patients with extensive nonobstructive CAD could have higher estimated risk than patients with obstructive CAD (stenosis >50%). Among patients with obstructive CAD, 12% had 5-year risk <10% whereas 24% had risk >20%. A similar large overlap in risk was found when revascularizations were excluded from the endpoint.
Conclusions
The 5-year risk for CVD events and death varies substantially in symptomatic patients undergoing CTA, even in the presence of obstructive CAD. These results provide support for individual risk assessment to improve potential benefit when allocating preventive therapies following CTA.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 15 Nov 2020; epub ahead of print
Mortensen MB, Steffensen FH, Bøtker HE, Jensen JM, ... Blaha MJ, Nørgaard BL
JACC Cardiovasc Imaging: 15 Nov 2020; epub ahead of print | PMID: 33221243
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Abstract

Evolution of Myocardial Dysfunction in Asymptomatic Patients at Risk of Heart Failure.

Halabi A, Yang H, Wright L, Potter E, ... Negishi K, Marwick TH
Objectives
The determinants of changes in systolic and diastolic parameters in patients aged >65 years, at risk of heart failure (HF), and with and without asymptomatic type 2 diabetes mellitus (T2DM) was assessed by echocardiography. The association between metformin and myocardial function was also assessed.
Background
The increasing prevalence of T2DM will likely further fuel the epidemic of HF. Understanding the development or progression of left ventricular (LV) dysfunction may inform effective measures for HF prevention.
Methods
A total of 982 patients with at least one HF risk factor (hypertension, obesity, or T2DM) were recruited from 2 community-based populations and divided into 2 groups: T2DM (n = 431, age 71 ± 4 years) and non-T2DM (n = 551, age 71 ± 5 years). Associations of metformin therapy were evaluated in the T2DM group. All underwent a comprehensive echocardiogram, including global longitudinal strain (GLS) and diastolic function (transmitral flow [E], annular velocity [e\']) at baseline and follow-up (median 19 months [interquartile range: 17-26]). Comparisons were facilitated by propensity matching.
Results
A reduction in GLS was observed in the T2DM group (baseline -17.8 ± 2.6% vs. follow-up -17.4 ± 2.8%; p = 0.003), but not in the non-T2DM group (-18.7 ± 2.7% vs. -18.6 ± 3.0%; p = 0.41). Estimated LV filling pressures increased in both the T2DM group (p = 0.001) and the non-T2DM group (p = 0.04). Metformin-treated patients with T2DM did not increase estimated LV filling pressure (E/e\' baseline 8.9 ± 2.7 vs. follow-up 9.1 ± 2.7; p = 0.485) or change e\' (7.6 ± 1.5 cm/s vs. 7.6 ± 1.8 cm/s; p = 0.88). After propensity matching, metformin was associated with a smaller change in e\' (β = 0.58 [95% CI 0.13 to 1.03]; p = 0.013) and E/e\' (β = -0.96 [95% CI -1.66 to -0.26]; p = 0.007) but was not associated with a change in GLS (p = 0.46).
Conclusions
Over 2 years, there is a worsening of GLS and LV filling pressures in asymptomatic diabetic patients with HF risk factors. Metformin use is associated with less deterioration of LV filling pressures and myocardial relaxation but had no association with systolic function.

Copyright © 2020. Published by Elsevier Inc.

JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print
Halabi A, Yang H, Wright L, Potter E, ... Negishi K, Marwick TH
JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print | PMID: 33221236
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Abstract

Regional Distribution of Fluorine-18-Flubrobenguane and Carbon-11-Hydroxyephedrine for Cardiac PET Imaging of Sympathetic Innervation.

Zelt JGE, Britt D, Mair BA, Rotstein BH, ... deKemp RA, Beanlands RS
Objectives
▪▪▪ Background: The sympathetic nervous system (SNS) is vitally linked to cardiovascular regulation and disease. SNS imaging has shown prognostic value. [C]meta-hydroxyephedrine (HED) is the most commonly used positron emission tomographic (PET) tracer for evaluation of sympathetic function in humans, but widespread clinical use is limited because of the short half-life of C. The aim of this study was to investigate the regional distribution of novel F-labeled PET tracer flubrobenguane (FBBG) (whose longer half-life could enable more widespread use) to assess myocardial pre-synaptic sympathetic nerve function in humans in comparison to HED.
Methods
A total of 25 participants (n = 6 healthy; n = 14 ischemic cardiomyopathy, left ventricular [LV] ejection fraction [EF] = 34 ± 5%; and n = 5 nonischemic cardiomyopathy, EF = 33 ± 3%) underwent 2 separate PET imaging visits 8.7 ± 7.6 days apart. On 1 visit, participants underwent dynamic HED PET imaging. On a different visit, participants underwent dynamic FBBG PET imaging. The order of testing was random. HED and FBBG global innervation (retention index [RI] and distribution volume [DV]) and regional denervation (% nonuniformity) were quantified to assess regional presynaptic sympathetic innervations.
Results
FBBG RI (r = 0.72; ICC = 0.79; p < 0.0001), DV (r = 0.62; ICC = 0.78; p < 0.0001), and regional denervation (r = 0.97; ICC = 0.98; p < 0.0001) correlated highly with HED. Average LV RI values were highly similar between HED (7.3 ± 2.4%/min) and FBBG (7.0 ± 1.7%/min; p = 0.33). Post-hoc analysis did not reveal any between-tracer differences on a regional level (17-segment), suggesting equivalent regional distributions in both patients with and without ischemic cardiomyopathy.
Conclusions
FBBG and HED yield equivalent global and regional distributions in both patients with and without ischemic cardiomyopathy. F-labeled PET tracers, such as FBBG, are critical for widespread distribution necessary for multicenter clinical trials and to maximize patient impact.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print
Zelt JGE, Britt D, Mair BA, Rotstein BH, ... deKemp RA, Beanlands RS
JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print | PMID: 33221229
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Abstract

Artificial Intelligence Aids Cardiac Image Quality Assessment for Improving Precision in Strain Measurements.

Huang KC, Huang CS, Su MY, Hung CL, ... Lin LC, Hwang JJ
Objectives
The aim of this study was to develop an artificial intelligence tool to assess echocardiographic image quality objectively.
Background
Left ventricular global longitudinal strain (LVGLS) has recently been used to monitor cancer therapeutics-related cardiac dysfunction (CTRCD) but image quality limits its reliability.
Methods
A DenseNet-121 convolutional neural network was developed for view identification from an athlete\'s echocardiographic dataset. To prove the concept that classification confidence (CC) can serve as a quality marker, values of longitudinal strain derived from feature tracking of cardiac magnetic resonance (CMR) imaging and strain analysis of echocardiography were compared. The CC was then applied to patients with breast cancer free from CTRCD to investigate the effects of image quality on the reliability of strain analysis.
Results
CC of the apical 4-chamber view (A4C) was significantly correlated with the endocardial border delineation index. CC of A4C >900 significantly predicted a <15% relative difference in longitudinal strain between CMR feature tracking and automated echocardiographic analysis. Echocardiographic studies (n =752) of 102 patients with breast cancer without CTRCD were investigated. The strain analysis showed higher parallel forms, inter-rater, and test-retest reliabilities in patients with CC of A4C >900. During sequential comparisons of automated LVGLS in individual patients, those with CC of A4C >900 had a lower false positive detection rate of CTRCD.
Conclusions
CC of A4C was associated with the reliability of automated LVGLS and could also potentially be used as a filter to select comparable images from sequential echocardiographic studies in individual patients and reduce the false positive detection rate of CTRCD.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 11 Nov 2020; epub ahead of print
Huang KC, Huang CS, Su MY, Hung CL, ... Lin LC, Hwang JJ
JACC Cardiovasc Imaging: 11 Nov 2020; epub ahead of print | PMID: 33221213
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Abstract

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

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

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

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

Eur Heart J Cardiovasc Imaging: 13 Nov 2020; epub ahead of print
Cosyns B, Haugaa KH, Gerber B, Gimelli A, ... Popescu BA, Edvardsen T
Eur Heart J Cardiovasc Imaging: 13 Nov 2020; epub ahead of print | PMID: 33188688
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Abstract

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

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

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

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

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

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

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

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

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

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

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

Eur Heart J Cardiovasc Imaging: 12 Nov 2020; epub ahead of print
Qiao HY, Li JH, Schoepf UJ, Bayer RR, ... Lu GM, Zhang LJ
Eur Heart J Cardiovasc Imaging: 12 Nov 2020; epub ahead of print | PMID: 33184644
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Abstract

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

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

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

Eur Heart J Cardiovasc Imaging: 16 Nov 2020; epub ahead of print
van Diemen PA, Wijmenga JT, Driessen RS, Bom MJ, ... Danad I, Knaapen P
Eur Heart J Cardiovasc Imaging: 16 Nov 2020; epub ahead of print | PMID: 33200201
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Abstract

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

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

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

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

Diabetic Cardiomiopathy Progression is Triggered by miR122-5p and Involves Extracellular Matrix: A 5-Year Prospective Study.

Pofi R, Giannetta E, Galea N, Francone M, ... Carbone I, Isidori AM
Objectives
The purpose of this study was to follow the long-term progression of diabetic cardiomyopathy by combining cardiac magnetic resonance (CMR) and molecular analysis.
Background
The evolution of diabetic cardiomyopathy to heart failure affects patients\'morbidity and mortality. CMR is the gold standard to assess cardiac remodeling, but there is a lack of markers linked to the mechanism of diabetic cardiomyopathy progression.
Methods
Five-year longitudinal study on patients with type 2 diabetes mellitus (T2DM) enrolled in the Cardiovascular Effects of Chronic Sildenafil in Men With Type 2 Diabetes (CECSID) trial (NCT00692237) compared with nondiabetic age-matched controls. CMR with tagging together with metabolic and molecular assessments were performed at baseline and 5-year follow-up.
Results
Seventy-nine men (age 64 ± 8 years) enrolled, comprising 59 men with T2DM compared with 20 nondiabetic age-matched controls. Longitudinal CMR with tagging showed an increase in ventricular mass (ΔLVMi = 13.47 ± 29.66 g/m; p = 0.014) and a borderline increase in end-diastolic volume (ΔEDVi = 5.16 ± 14.71 ml/m; p = 0.056) in men with T2DM. Cardiac strain worsened (Δσ = 1.52 ± 3.85%; p = 0.033) whereas torsion was unchanged (Δθ = 0.24 ± 4.04°; p = 0.737), revealing a loss of the adaptive equilibrium between strain and torsion. Contraction dynamics showed a decrease in the systolic time-to-peak (ΔTtP = -35.18 ± 28.81 ms; p < 0.001) and diastolic early recoil-rate (ΔRR = -20.01 ± 19.07 s; p < 0.001). The ejection fraction and metabolic parameters were unchanged. Circulating miR microarray revealed an up-regulation of miR122-5p. Network analysis predicted the matrix metalloproteinases (MMPs) MMP-16 and MMP-2 and their regulator (tissue inhibitors of metalloproteinases) as targets. In db/db mice we demonstrated that miR122-5p expression is associated with diabetic cardiomyopathy, that in the diabetic heart is overexpressed, and that, in vitro, it regulates MMP-2. Finally, we demonstrated that miR122-5p overexpression affects the extracellular matrix through MMP-2 modulation.
Conclusions
Within 5 years of diabetic cardiomyopathy onset, increasing cardiac hypertrophy is associated with progressive impairment in strain, depletion of the compensatory role of torsion, and changes in viscoelastic contraction dynamics. These changes are independent of glycemic control and paralleled by the up-regulation of specific microRNAs targeting the extracellular matrix (Cardiovascular Effects of Chronic Sildenafil in Men With Type 2 Diabetes [CECSID]; NCT00692237).

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print
Pofi R, Giannetta E, Galea N, Francone M, ... Carbone I, Isidori AM
JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print | PMID: 33221242
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Abstract

Early Mechanical Alterations in Phospholamban Mutation Carriers: Identifying Subclinical Disease Before Onset of Symptoms.

Taha K, Te Rijdt WP, Verstraelen TE, Cramer MJ, ... van den Berg MP, Teske AJ
Objectives
This study aimed to explore echocardiographic characteristics of phospholamban (PLN) p.Arg14del mutation carriers to investigate whether structural and/or functional abnormalities could be identified before onset of symptoms.
Background
Carriers of the genetic PLN p.Arg14del mutation may develop arrhythmogenic and/or dilated cardiomyopathy. Overt disease is preceded by a pre-symptomatic phase of variable length in which disease expression seems to be absent.
Methods
PLN p.Arg14del mutation carriers with an available echocardiogram were included. Mutation carriers were classified as pre-symptomatic if they had no history of ventricular arrhythmias (VAs), a premature ventricular complex count of <500/24 h, and a left ventricular (LV) ejection fraction of ≥45%. In addition, we included 70 control subjects with similar age and sex distribution as the pre-symptomatic mutation carriers. Comprehensive echocardiographic analysis (including deformation imaging) was performed.
Results
The final study population consisted of 281 PLN p.Arg14del mutation carriers, 139 of whom were classified as pre-symptomatic. In comparison to control subjects, pre-symptomatic mutation carriers had lower global longitudinal strain and higher LV mechanical dispersion (both p < 0.001). In addition, post-systolic shortening (PSS) in the LV apex was observed in 43 pre-symptomatic mutation carriers (31%) and in none of the control subjects. During a median follow-up of 3.2 years (interquartile range: 2.1 to 5.6 years) in 104 pre-symptomatic mutation carriers, nonsustained VA occurred in 13 (13%). Presence of apical PSS was the strongest echocardiographic predictor of VA (multivariable hazards ratio: 5.11; 95% confidence interval [CI]: 1.37 to 19.08; p = 0.015), which resulted in a negative predictive value of 96% (95% CI: 89% to 98%) and a positive predictive value of 29% (95% CI: 21% to 40%).
Conclusions
Global and regional LV mechanical alterations in PLN p.Arg14del mutation carriers precede arrhythmic symptoms and overt structural disease. Pre-symptomatic mutation carriers with normal deformation patterns in the apex are at low risk of developing VA within 3 years, whereas mutation carriers with apical PSS appear to be at higher risk.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print
Taha K, Te Rijdt WP, Verstraelen TE, Cramer MJ, ... van den Berg MP, Teske AJ
JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print | PMID: 33221241
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Abstract

Structural and Functional Correlates of Gradient-Area Patterns in Severe Aortic Stenosis and Normal Ejection Fraction.

Slimani A, Roy C, de Meester C, Bouzin C, ... Gerber BL, Vanoverschelde JL
Objectives
The authors sought to characterize the functional and structural myocardial phenotypes of patients with moderate-to-severe aortic stenosis (AS) and to determine whether severe paradoxical low-gradient AS (LG-AS) is specifically associated with left ventricular (LV) remodeling and fibrosis.
Background
Recently, it was suggested that severe paradoxical LG-AS is a more advanced form of AS, with greater reduction of longitudinal deformation, adverse LV remodeling, and more interstitial fibrosis.
Methods
The study population includes 147 patients with moderate-to-severe AS and a normal LV ejection fraction, and 75 normal control subjects. They prospectively underwent 2-dimensional speckle-tracking echocardiography and cardiac magnetic resonance to evaluate myocardial deformation, LV remodeling, and age- and sex-adjusted extravascular volume fraction (ECV, %). Among AS patients, 18 had moderate AS, 74 had severe high-gradient AS (HG-AS), and 55 had severe paradoxical LG-AS.
Results
Reduced longitudinal and circumferential deformation was observed in 21% and 6% of the AS patients, respectively. Multivariate analyses identified increased ECV (ß = 1.99; p = 0.001) and the absence of normal LV geometry (ß = -1.37; p = 0.007) and as independent predictors of reduced longitudinal deformation. Increased ECV was an independent predictor of reduced circumferential deformation (ß = 2.19; p = 0.001). Over a median follow-up of 29 months, reduced longitudinal deformation (hazard ratio: 0.82; p = 0.023) and higher transvalvular gradients (hazard ratio: 1.05; p < 0.001) increased the risk of death or need for aortic valve replacement. LV hypertrophy was more frequently observed among patients with severe HG-AS (65%) than among the other AS patients (14%; p < 0.001). On average, ECV was within normal limits and did not differ among gradient-area subgroups. When present, increased ECV was associated with reduced longitudinal deformation.
Conclusions
This study\'s data show that patients with severe paradoxical LG-AS less frequently display reduced longitudinal deformation, LV hypertrophy, or myocardial fibrosis than patients with HG-AS. Also, interstitial fibrosis only occurs when reduced longitudinal deformation and severe HG-AS are present together. Finally, this study suggests that reduced longitudinal deformation and higher transvalvular gradients adversely affect patients\' outcomes.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print
Slimani A, Roy C, de Meester C, Bouzin C, ... Gerber BL, Vanoverschelde JL
JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print | PMID: 33221240
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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 © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 11 Nov 2020; epub ahead of print
Chou TH, Alvelo JL, Janse S, Papademetris X, ... Sinusas AJ, Stacy MR
JACC Cardiovasc Imaging: 11 Nov 2020; epub ahead of print | PMID: 33221224
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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 © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print
Bec J, Vela D, Phipps JE, Agung M, ... Buja LM, Marcu L
JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print | PMID: 33221238
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Abstract

Coronary Artery Calcium to Improve the Efficiency of Randomized Controlled Trials in Primary Cardiovascular Prevention.

Cainzos-Achirica M, Bittencourt MS, Osei AD, Haque W, ... Blaha MJ, Nasir K
Objectives
This study sought to assess the value, in terms of sample size and cost, of using the coronary artery calcium (CAC) score to enrich the study population of primary prevention randomized controlled trials (RCTs) with participants at high absolute risk of atherosclerotic cardiovascular disease (ASCVD) events.
Background
The feasibility of RCTs assessing the efficacy of novel add-on therapies for primary prevention among high-risk individuals treated with statins may be limited by sample size and cost.
Methods
We evaluated 3,075 statin-naive participants from the Multi-Ethnic Study of Atherosclerosis with estimated 10-year ASCVD risk of ≥7.5%. CAC of >100, CAC of >400, high sensitivity C-reactive protein levels of >2 and >3 mg/l, ankle-brachial index of <0.9, and triglyceride levels of >175 mg/dl were each evaluated as enrichment criteria on top of estimated ASCVD risk of ≥7.5%, ≥10%, ≥15% and ≥20%. For each criterion, using the observed 5-year incidence of CVD, we projected the incidence of CVD assuming a 28% relative risk reduction with high-intensity statin therapy and after addition of novel therapy with additive relative risk reductions of 15% and 25%. Sample size and cost of a hypothetical primary prevention 5-year RCT of a novel therapy on top of statins versus statins alone were then computed by using the projected incidences. Yearly costs per included participant of $6,000 to $9,000 and of $500/$600 per screened nonparticipant were assumed.
Results
CAC of >400, present in 15% to 23% participants, consistently identified the subgroups with highest 5-year incident events and outperformed the other features yielding the smallest projected sample size, ranging 33% to 58% lower than using risk estimations alone for participant selection. CAC of >400 also yielded the lowest projected RCT costs, at least $40 million lower than using risk estimations alone. CAC of >100 showed the second-best performance in most scenarios.
Conclusions
High CAC scores used as study entry criteria can improve the efficiency and feasibility of primary prevention RCTs evaluating the incremental efficacy of novel add-on therapies.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print
Cainzos-Achirica M, Bittencourt MS, Osei AD, Haque W, ... Blaha MJ, Nasir K
JACC Cardiovasc Imaging: 12 Nov 2020; epub ahead of print | PMID: 33221237
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Abstract

NIRS-IVUS for Differentiating Coronary Plaque Rupture, Erosion and Calcified Nodule in Acute Myocardial Infarction.

Terada K, Kubo T, Kameyama T, Matsuo Y, ... Madder RD, Akasaka T
Objectives
This study sought to investigate the ability of combined near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS) to differentiate plaque rupture (PR), plaque erosion (PE), or calcified nodule (CN) in acute myocardial infarction (AMI).
Background
Most acute coronary syndromes occur from coronary thrombosis based on PR, PE, or CN. In vivo differentiation among PR, PE, and CN is a major challenge for intravascular imaging.
Methods
The study enrolled 244 patients with AMI who had a de novo culprit lesion in a native coronary artery. The culprit lesions were assessed by both NIRS-IVUS and optical coherence tomography (OCT). Maximum lipid core burden index in 4 mm (maxLCBI) was measured by NIRS. Plaque cavity and convex calcium was detected by IVUS. The OCT diagnosis of PR (n = 175), PE (n = 44), and CN (n = 25) was used as a reference standard.
Results
In the development cohort, IVUS-detected plaque cavity showed a high specificity (100%) and intermediate sensitivity (62%) for identifying OCT-PR. IVUS-detected convex calcium showed a high sensitivity (93%) and specificity (100%) for identifying OCT-CN. NIRS-measured maxLCBI was largest in OCT-PR (705 [interquartile range (IQR): 545 to 854]), followed by OCT-CN (355 [IQR: 303 to 478]) and OCT-PE (300 [IQR: 126 to 357]) (p < 0.001). The optimal cutoff value of maxLCBI was 426 for differentiating between OCT-PR and -PE; 328 for differentiating between OCT-PE and -CN; and 579 for differentiating between OCT-PR and -CN. In the validation cohort, the NIRS-IVUS classification algorithm using plaque cavity, convex calcium, and maxLCBI showed a sensitivity and specificity of 97% and 96% for identifying OCT-PR, 93% and 99% for OCT-PE, and 100% and 99% for OCT-CN, respectively.
Conclusions
By evaluating plaque cavity, convex calcium, and maxLCBI, NIRS-IVUS can accurately differentiate PR, PE, and CN.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 11 Nov 2020; epub ahead of print
Terada K, Kubo T, Kameyama T, Matsuo Y, ... Madder RD, Akasaka T
JACC Cardiovasc Imaging: 11 Nov 2020; epub ahead of print | PMID: 33221211
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Abstract

The Relationship Between Coronary Calcification and the Natural History of Coronary Artery Disease.

Jin HY, Weir-McCall JR, Leipsic JA, Son JW, ... Lee SE, Chang HJ
Objectives
The aim of the current study was to explore the impact of plaque calcification in terms of absolute calcified plaque volume (CPV) and in the context of its percentage of the total plaque volume at a lesion and patient level on the progression of coronary artery disease.
Background
Coronary artery calcification is an established marker of risk of future cardiovascular events. Despite this, plaque calcification is also considered a marker of plaque stability, and it increases in response to medical therapy.
Methods
This analysis included 925 patients with 2,568 lesions from the PARADIGM (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging) registry, in which patients underwent clinically indicated serial coronary computed tomography angiography. Plaque calcification was examined by using CPV and percent CPV (PCPV), calculated as (CPV/plaque volume) × 100 at a per-plaque and per-patient level (summation of all individual plaques).
Results
CPV was strongly correlated with plaque volume (r = 0.780; p < 0.001) at baseline and with plaque progression (r = 0.297; p < 0.001); however, this association was reversed after accounting for plaque volume at baseline (r = -0.146; p < 0.001). In contrast, PCPV was an independent predictor of a reduction in plaque volume (r = -0.11; p < 0.001) in univariable and multivariable linear regression analyses. Patient-level analysis showed that high CPV was associated with incident major adverse cardiac events (hazard ratio: 3.01: 95% confidence interval: 1.58 to 5.72), whereas high PCPV was inversely associated with major adverse cardiac events (hazard ratio: 0.529; 95% confidence interval: 0.229 to 0.968) in multivariable analysis.
Conclusions
Calcified plaque is a marker for risk of adverse events and disease progression due to its strong association with the total plaque burden. When considered as a percentage of the total plaque volume, increasing PCPV is a marker of plaque stability and reduced risk at both a lesion and patient level. (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging [PARADIGM]; NCT02803411).

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 11 Nov 2020; epub ahead of print
Jin HY, Weir-McCall JR, Leipsic JA, Son JW, ... Lee SE, Chang HJ
JACC Cardiovasc Imaging: 11 Nov 2020; epub ahead of print | PMID: 33221216
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Abstract

Mortality Prediction by Quantitative PET Perfusion Expressed as Coronary Flow Capacity With and Without Revascularization.

Gould KL, Kitkungvan D, Johnson NP, Nguyen T, ... Zhu H, Lai D
Objectives
This study sought to determine the relationship between the severity of reduced quantitative perfusion parameters and mortality with and without revascularization.
Background
The physiological mechanisms for differential mortality risk of coronary flow reserve (CFR) and coronary flow capacity (CFC) before and after revascularization are unknown.
Methods
Global and regional rest-stress (ml/min/g), CFR, their regional per-pixel combination as CFC, and relative stress in ml/min/g were measured as percent of LV in all serial routine 5,274 diagnostic PET scans with systematic follow-up over 10 years (mean 4.2 ± 2.5 years) for all-cause mortality with and without revascularization.
Results
Severely reduced CFR of 1.0 to 1.5 and stress perfusion ≤1.0 cc/min/g incurred increasing size-dependent risks that were additive because regional severely reduced CFC (CFCsevere) was associated with the highest major adverse cardiac event rate of 80% (p < 0.0001 vs. either alone) and a mortality risk of 14% (vs. 2.3% for no CFCsevere; p = 0.001). Small regions of CFCsevere ≤0.5% predicted high risk (p < 0.0001 vs. no CFCsevere) related to a wave front of border zones at risk around the small most severe center. By receiver-operating characteristic analysis, relative stress topogram maps of stress (ml/min/g) as a fraction of LV defined these border zones at risk or for mildly reduced CFC (area under the curve [AUC]: 0.69) with a reduced relative tomographic subendocardial-to-subepicardial ratio. CFCsevere incurred the highest mortality risk that was reduced by revascularization (p = 0.005 vs. no revascularization) for artery-specific stenosis not defined by global CFR or stress perfusion alone.
Conclusions
CFC is associated with the size-dependent highest mortality risk resulting from the additive risk of CFR and stress (ml/min/g) that is significantly reduced after revascularization, a finding not seen for global CFR. Small regions of CFCsevere ≤0.5% of LV also carry a high risk because of the surrounding border zones at risk defined by relative stress perfusion and a reduced relative subendocardial-to-subepicardial ratio.

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 15 Nov 2020; epub ahead of print
Gould KL, Kitkungvan D, Johnson NP, Nguyen T, ... Zhu H, Lai D
JACC Cardiovasc Imaging: 15 Nov 2020; epub ahead of print | PMID: 33221205
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Abstract

Diagnosing Transthyretin Cardiac Amyloidosis by Technetium 99m Pyrophosphate: A Test in Evolution.

Poterucha TJ, Elias P, Bokhari S, Einstein AJ, ... Perotte A, Maurer MS
Objectives
This study aimed to characterize trends in technetium Tc 99m pyrophosphate (Tc-PYP) scanning for amyloid transthyretin cardiac amyloidosis (ATTR-CA) diagnosis, to determine whether patients underwent appropriate assessment with monoclonal protein and genetic testing, to evaluate use of single-photon emission computed tomography (SPECT) in addition to planar imaging, and to identify predictive factors for ATTR-CA.
Background
Tc-PYP scintigraphy has been repurposed for noninvasive diagnosis of ATTR-CA. Increasing use of Tc-PYP can facilitate identification of ATTR-CA, but appropriate use is critical for accurate diagnosis in an era of high-cost targeted therapeutics.
Methods
Patients undergoing Tc-PYP scanning 1 h after injection at a quaternary care center from 2010 to 2019 were analyzed; clinical information was abstracted; and SPECT results were analyzed.
Results
Over the decade, endomyocardial biopsy rates remained stable with scanning rates peaking at 132 in 2019 (p < 0.001). Among 753 patients (516 men, mean age 77 years), 307 (41%) had a visual score of 0, 177 (23%) of 1, and 269 (36%) of 2 or 3. Of 751 patients with analyzable heart to contralateral chest ratios, 249 (33%) had a ratio ≥1.5. Monoclonal protein testing status was assessed in 550 patients, of these, 174 (32%) did not undergo both serum immunofixation and serum free light chain analysis tests, and 331 (60%) did not undergo all 3 tests-serum immunofixation, serum free light chain analysis, and urine protein electrophoresis. Of 196 patients with confirmed ATTR-CA, 143 (73%) had genetic testing for transthyretin mutations. In 103 patients undergoing cardiac biopsy, grades 2 and 3 99mTc-PYP had sensitivity of 94% and specificity of 89% for ATTR-CA with 100% specificity for grade 3 scans. With respect to SPECT as a reference standard, planar imaging had false positive results in 16 of 25 (64%) grade 2 scans.
Conclusions
Use of noninvasive testing with Tc-PYP scanning for evaluation of ATTR-CA is increasing, and the inclusion of monoclonal protein testing and SPECT imaging is crucial to rule out amyloid light chain amyloidosis and distinguish myocardial retention from blood pooling.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 11 Nov 2020; epub ahead of print
Poterucha TJ, Elias P, Bokhari S, Einstein AJ, ... Perotte A, Maurer MS
JACC Cardiovasc Imaging: 11 Nov 2020; epub ahead of print | PMID: 33221204
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Abstract

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Progression of Myocardial Fibrosis in Hypertrophic Cardiomyopathy: A Cardiac Magnetic Resonance Study.

Habib M, Adler A, Fardfini K, Hoss S, ... Rakowski H, Chan RH
Objectives
This study examined fibrosis progression in hypertrophic cardiomyopathy (HCM) patients, as well as its relationship to patient characteristics, clinical outcomes, and its effect on clinical decision making.
Background
Myocardial fibrosis, as quantified by late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR), provides valuable prognostic information in patients with HCM.
Methods
A total of 157 patients with HCM were enrolled in this study, with 2 sequential CMR scans separated by an interval of 4.7 ± 1.9 years.
Results
At the first CMR session (CMR-1), 70% of patients had LGE compared with 85% at CMR-2 (p = 0.001). The extent of LGE extent increased between the 2 CMR procedures, from 4 ± 5.6% to 6.3 ± 7.4% (p < 0.0001), with an average LGE progression rate of 0.5% ± 1.0%/year. LGE mass progression was correlated with higher LGE mass and extent on CMR-1 (p = 0.0017 and 0.007, respectively), greater indexed left ventricular (LV) mass (p < 0.0001), greater LV maximal wall thickness (p < 0.0001), apical aneurysm at CMR-1 (p < 0.0001), and lower LV ejection fraction (EF) (p = 0.029). Patients who were more likely to have a higher rate of LGE progression presented with more severe disease at baseline, characterized by LGE extent >8% of LV mass, indexed LV mass >100 g/m, maximal wall thickness ≥20 mm, LVEF ≤60%, and apical aneurysm. There was a significant correlation between the magnitude of LGE progression and future implantation of insertable cardioverter-defibrillators (p = 0.004), EF deterioration to ≤50% (p < 0.0001), and admission for heart failure (p = 0.0006).
Conclusions
Myocardial fibrosis in patients with HCM is a slowly progressive process. Progression of LGE is significantly correlated with a number of clinical outcomes such as progression to EF ≤50% and heart failure admission. Judicious use of serial CMR with LGE can provide valuable information to help patient management.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print
Habib M, Adler A, Fardfini K, Hoss S, ... Rakowski H, Chan RH
JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print | PMID: 33248971
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Abstract

Magnetic Resonance Mapping of Catheter Ablation Lesions After Post-Infarction Ventricular Tachycardia Ablation.

Dabbagh GS, Ghannam M, Siontis KC, Attili A, ... Morady F, Bogun F
Objectives
This study sought to describe cardiac magnetic resonance (CMR) characteristics of ablation lesions within post-infarction scar.
Background
Chronic ablation lesions created during radiofrequency ablation of ventricular tachycardia (VT) in the setting of prior myocardial infarction have not been described in humans.
Methods
Seventeen patients (15 men, ejection fraction 25 ± 8%, 66 ± 6 years of age) with CMR imaging prior to repeat ablation procedures for VT were studied. Electroanatomic maps from first-time procedures and subsequent CMR images were merged and retrospectively compared with electroanatomic maps from repeat procedures.
Results
The delay between the index ablation procedure and the CMR study was 30 ± 29 months. Late gadolinium-enhanced CMR revealed a confluent nonenhancing subendocardial dark core within the infarct-related scar tissue in all patients. Intracardiac thrombi were ruled out by transthoracic and intracardiac echocardiography. These core lesions matched the distribution of prior ablation lesions, and corresponded to unexcitable areas at repeat procedures.
Conclusions
Ablation lesions can be detected by CMR after VT ablation in post-infarction patients and have a different appearance than scar tissue. These lesions can be observed many months after an initial ablation.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print
Dabbagh GS, Ghannam M, Siontis KC, Attili A, ... Morady F, Bogun F
JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print | PMID: 33248970
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Abstract

High-Resolution Cardiac Magnetic Resonance Imaging Techniques for the Identification of Coronary Microvascular Dysfunction.

Rahman H, Scannell CM, Demir OM, Ryan M, ... Perera D, Chiribiri A
Objectives
This study assessed the ability to identify coronary microvascular dysfunction (CMD) in patients with angina and nonobstructive coronary artery disease (NOCAD) using high-resolution cardiac magnetic resonance (CMR) and hypothesized that quantitative perfusion techniques would have greater accuracy than visual analysis.
Background
Half of all patients with angina are found to have NOCAD, while the presence of CMD portends greater morbidity and mortality, it now represents a modifiable therapeutic target. Diagnosis currently requires invasive assessment of coronary blood flow during angiography. With greater reliance on computed tomography coronary angiography as a first-line tool to investigate angina, noninvasive tests for diagnosing CMD warrant validation.
Methods
Consecutive patients with angina and NOCAD were enrolled. Intracoronary pressure and flow measurements were acquired during rest and vasodilator-mediated hyperemia. CMR (3-T) was performed and analyzed by visual and quantitative techniques, including calculation of myocardial blood flow (MBF) during hyperemia (stress MBF), transmural myocardial perfusion reserve (MPR: MBF / MBF), and subendocardial MPR (MPR). CMD was defined dichotomously as an invasive coronary flow reserve <2.5, with CMR readers blinded to this classification.
Results
A total of 75 patients were enrolled (57 ± 10 years of age, 81% women). Among the quantitative perfusion indices, MPR and MPR had the highest accuracy (area under the curve [AUC]: 0.90 and 0.88) with high sensitivity and specificity, respectively, both superior to visual assessment (both p < 0.001). Visual assessment identified CMD with 58% accuracy (41% sensitivity and 83% specificity). Quantitative stress MBF performed similarly to visual analysis (AUC: 0.64 vs. 0.60; p = 0.69).
Conclusions
High-resolution CMR has good accuracy at detecting CMD but only when analyzed quantitatively. Although omission of rest imaging and stress-only protocols make for quicker scans, this is at the cost of accuracy compared with integrating rest and stress perfusion. Quantitative perfusion CMR has an increasingly important role in the management of patients frequently encountered with angina and NOCAD.

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print
Rahman H, Scannell CM, Demir OM, Ryan M, ... Perera D, Chiribiri A
JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print | PMID: 33248969
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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 © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print
Collet C, Sonck J, Leipsic J, Monizzi G, ... Andreini D, De Bruyne B
JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print | PMID: 33248968
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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 © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print
Myerson SG
JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print | PMID: 33248967
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Impact:
Abstract

Long-Term Prognosis of Patients With Coronary Microvascular Disease Using Stress Perfusion Cardiac Magnetic Resonance.

Zhou W, Lee JCY, Leung ST, Lai A, ... Pennell DJ, Ng MY
Objectives
This study investigated the prognosis of coronary microvascular disease (CMD) as determined by stress perfusion cardiac magnetic resonance (CMR) in patients with ischemic symptoms but without significant coronary artery disease (CAD).
Background
Patients with CMD have poorer prognosis with various cardiac diseases. The myocardial perfusion reserve index (MPRI) derived from noninvasive stress perfusion CMR has been established to diagnose microvascular angina with a threshold MPRI <1.4. The prognosis of CMD as determined by MPRI is unknown.
Methods
Chest pain patients without epicardial CAD or myocardial disease from January 2009 to December 2017 were retrospectively included from 3 imaging centers in Hong Kong (HK). Stress perfusion CMR examinations were performed using either adenosine or adenosine triphosphate. Adequate stress was assessed by achieving splenic switch-off sign. Measurement of MPRI was performed in all stress perfusion CMR scans. Patients were followed for major adverse cardiovascular events defined as all-cause death, acute coronary syndrome (ACS), epicardial CAD development, heart failure hospitalization and non-fatal stroke.
Results
A total of 218 patients were studied (mean age 59 ± 12 years; 49.5% male) and the average MPRI of that cohort was 1.56 ± 0.33. Females and a history of hyperlipidemia were predictors of lower MPRI. Major adverse cardiovascular events (MACE) occurred in 15.6% of patients during a median follow-up of 5.5 years (interquartile range: 4.6 to 6.8 years). The optimal cutoff value of MPRI in predicting MACE was found with a threshold MPRI ≤1.47. Patients with MPRI ≤1.47 had three-fold increased risk of MACE compared with those with MPRI >1.47 (hazard ratio [HR]: 3.14; 95% confidence interval [CI]: 1.58 to 6.25; p = 0.001). Multivariate Cox regression after adjusting for age and hypertension demonstrated that MPRI was an independent predictor of MACE (HR: 0.10; 95% CI: 0.03 to 0.34; p < 0.001).
Conclusion
Stress perfusion CMR-derived MPRI is an independent imaging marker that predicts MACE in patients with ischemic symptom and no overt CAD over the medium term.

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print
Zhou W, Lee JCY, Leung ST, Lai A, ... Pennell DJ, Ng MY
JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print | PMID: 33248966
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Abstract

Neo-LVOT and Transcatheter Mitral Valve Replacement: Expert Recommendations.

Reid A, Ben Zekry S, Turaga M, Tarazi S, ... Blanke P, Leipsic J

With the advent of transcatheter mitral valve replacement (TMVR), the concept of the neo-left ventricular outflow tract (LVOT) was introduced and remains an essential component of treatment planning. This paper describes the LVOT anatomy and provides a step-by-step computed tomography methodology to segment and measure the neo-LVOT while discussing the current evidence and outstanding challenges. It also discusses the technical and hemodynamic factors that play a major role in assessing the neo-LVOT. A summary of expert-based recommendations about the overall risk of LVOT obstruction in different scenarios is presented along with the currently available methods to reduce the risk of LVOT obstruction and other post-procedural complications.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print
Reid A, Ben Zekry S, Turaga M, Tarazi S, ... Blanke P, Leipsic J
JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print | PMID: 33248959
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Impact:
Abstract

CT Angiographic and Plaque Predictors of Functionally Significant Coronary Disease and Outcome Using Machine Learning.

Yang S, Koo BK, Hoshino M, Lee JM, ... Kakuta T, Narula J
Objectives
The goal of this study was to investigate the association of stenosis and plaque features with myocardial ischemia and their prognostic implications.
Background
Various anatomic, functional, and morphological attributes of coronary artery disease (CAD) have been independently explored to define ischemia and prognosis.
Methods
A total of 1,013 vessels with fractional flow reserve (FFR) measurement and available coronary computed tomography angiography were analyzed. Stenosis and plaque features of the target lesion and vessel were evaluated by an independent core laboratory. Relevant features associated with low FFR (≤0.80) were identified by using machine learning, and their predictability of 5-year risk of vessel-oriented composite outcome, including cardiac death, target vessel myocardial infarction, or target vessel revascularization, were evaluated.
Results
The mean percent diameter stenosis and invasive FFR were 48.5 ± 17.4% and 0.81 ± 0.14, respectively. Machine learning interrogation identified 6 clusters for low FFR, and the most relevant feature from each cluster was minimum lumen area, percent atheroma volume, fibrofatty and necrotic core volume, plaque volume, proximal left anterior descending coronary artery lesion, and remodeling index (in order of importance). These 6 features showed predictability for low FFR (area under the receiver-operating characteristic curve: 0.797). The risk of 5-year vessel-oriented composite outcome increased with every increment of the number of 6 relevant features, and it had incremental prognostic value over percent diameter stenosis and FFR (area under the receiver-operating characteristic curve: 0.706 vs. 0.611; p = 0.031).
Conclusions
Six functionally relevant features, including minimum lumen area, percent atheroma volume, fibrofatty and necrotic core volume, plaque volume, proximal left anterior descending coronary artery lesion, and remodeling index, help define the presence of myocardial ischemia and provide better prognostication in patients with CAD. (CCTA-FFR Registry for Risk Prediction; NCT04037163).

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print
Yang S, Koo BK, Hoshino M, Lee JM, ... Kakuta T, Narula J
JACC Cardiovasc Imaging: 18 Nov 2020; epub ahead of print | PMID: 33248965
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Impact:
Abstract

Is a timely assessment of the hematocrit necessary for cardiovascular magnetic resonance-derived extracellular volume measurements?

Su MY, Huang YS, Niisato E, Chow K, ... Yang SC, Chang YC
Background
Cardiovascular magnetic resonance (CMR)-derived extracellular volume (ECV) requires a hematocrit (Hct) to correct contrast volume distributions in blood. However, the timely assessment of Hct can be challenging and has limited the routine clinical application of ECV. The goal of the present study was to evaluate whether ECV measurements lead to significant error if a venous Hct was unavailable on the day of CMR.
Methods
109 patients with CMR T1 mapping and two venous Hcts (Hct: a Hct from the day of CMR, and Hct: a Hct from a different day) were retrospectively identified. A synthetic Hct (Hct) derived from native blood T1 was also assessed. The study used two different ECV methods, (1) a conventional method in which ECV was estimated from native and postcontrast T1 maps using a region-based method, and (2) an inline method in which ECV was directly measured from inline ECV mapping. ECVs measured with Hct, Hct, and Hct were compared for each method, and the reference ECV (ECV) was defined using the Hct. The error between synthetic (ECV) and ECVwas analyzed for the two ECV methods.
Results
ECV measured using Hct and Hct were significantly correlated with ECV for each method. No significant differences were observed between ECV and ECV measured with Hct (ECV; 28.4 ± 6.6% vs. 28.3 ± 6.1%, p = 0.789) and between ECV and ECV calculated with Hct (ECV; 28.4 ± 6.6% vs. 28.2 ± 6.2%, p = 0.45) using the conventional method. Similarly, ECV was not significantly different from ECV (28.5 ± 6.7% vs. 28.5 ± 6.2, p = 0.801) and ECV (28.5 ± 6.7% vs. 28.4 ± 6.0, p = 0.974) using inline method. ECV values revealed relatively large discrepancies in patients with lower Hcts compared with those with higher Hcts.
Conclusions
Venous Hcts measured on a different day from that of the CMR examination can still be used to measure ECV. ECV can provide an alternative method to quantify ECV without needing a blood sample, but significant ECV errors occur in patients with severe anemia.



J Cardiovasc Magn Reson: 29 Nov 2020; 22:77
Su MY, Huang YS, Niisato E, Chow K, ... Yang SC, Chang YC
J Cardiovasc Magn Reson: 29 Nov 2020; 22:77 | PMID: 33250055
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Abstract

Serial Cardiovascular Magnetic Resonance Strain Measurements to Identify Cardiotoxicity in Breast Cancer: Comparison With Echocardiography.

Houbois CP, Nolan M, Somerset E, Shalmon T, ... Wintersperger BJ, Thavendiranathan P
Objectives
This study sought to compare the prognostic value of cardiovascular magnetic resonance (CMR) and 2-dimensional echocardiography (2DE) derived left ventricular (LV) strain, volumes, and ejection fraction for cancer therapy-related cardiac dysfunction (CTRCD) in women with early stage breast cancer.
Background
There are limited comparative data on the association of CMR and 2DE derived strain, volumes, and LVEF with CTRCD.
Methods
A total of 125 prospectively recruited women with HER2+ early stage breast cancer receiving sequential anthracycline/trastuzumab underwent 5 serial CMR and 6 of 2DE studies before and during treatment. CMR LV volumes, left ventricular ejection fraction tagged-CMR, and feature-tracking (FT) derived global systolic longitudinal (GLS) and global circumferential strain (GCS) and 2DE-based LV volumes, function, GLS, and GCS were measured. CTRCD was defined by the cardiac review and evaluation committee criteria.
Results
Twenty-eight percent of patients developed CTRCD by CMR and 22% by 2DE. A 15% relative reduction in 2DE-GLS increased the CTRCD odds by 133% at subsequent follow-up, compared with 47%/50% by tagged-CMR GLS/GCS and 87% by FT-GCS. CMR and 2DE-LVEF and indexed left ventricular end-systolic volume (LVESVi) were also associated with subsequent CTRCD. The prognostic threshold change in CMR-left ventricular ejection fraction and FT strain for subsequent CTRCD was similar to the known minimum-detectable difference for these measures, whereas for tagged-CMR strain it was lower than the minimum-detectable difference; for 2DE, only the prognostic threshold for GLS was greater than the minimum-detectable difference. Of all strain methods, 2DE-GLS provided the highest increase in discriminatory value over baseline clinical risk factors for subsequent CTRCD. The combination of 2DE-left ventricular ejection fraction or LVESVi and strain provided greater increase in the area under the curve for subsequent CTRCD over clinical risk factors than CMR left ventricular ejection fraction or LVESVi and strain (18% to 22% vs. 9% to 14%).
Conclusions
In women with HER2+ early stage breast cancer, changes in CMR and 2DE strain, left ventricular ejection fraction, and LVESVi were prognostic for subsequent CTRCD. When LVEF can be measured precisely by CMR, FT strain may function as an additional confirmatory prognostic measure, but with 2DE, GLS is the optimal prognostic measure. (Evaluation of Myocardial Changes During BReast Adenocarcinoma Therapy to Detect Cardiotoxicity Earlier With MRI [EMBRACE-MRI]; NCT02306538).

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 24 Nov 2020; epub ahead of print
Houbois CP, Nolan M, Somerset E, Shalmon T, ... Wintersperger BJ, Thavendiranathan P
JACC Cardiovasc Imaging: 24 Nov 2020; epub ahead of print | PMID: 33248962
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Abstract

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

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

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

Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1405-1411
Burocchi S, Gori M, Cioffi G, Calabrese A, ... Gavazzi A, Senni M
Eur Heart J Cardiovasc Imaging: 30 Nov 2020; 21:1405-1411 | PMID: 31808506
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Abstract

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

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

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

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