Topic: Imaging

Abstract

Additive effect of hypertension on left ventricular structure and function in patients with asymptomatic type 2 diabetes mellitus.

Jiang L, Ren Y, Yu H, Guo YK, ... Han PL, Yang ZG
Objective
We aimed to comprehensively determine the effects of hypertension on left ventricular (LV) structure, microcirculation, tissue characteristics, and deformation in type 2 diabetes mellitus (T2DM) using multiparametric cardiac magnetic resonance (CMR) imaging.
Methods
We prospectively enrolled 138 asymptomatic patients with T2DM (80 normotensive and 58 hypertensive individuals) and 42 normal glucose-tolerant and normotensive controls and performed multiparametric CMR examination to assess cardiac geometry, microvascular perfusion, extracellular volume (ECV), and strain. Univariable and multivariable linear analysis was performed to analyze the effect of hypertension on LV deformation in patients with T2DM.
Results
Compared with controls, patients with T2DM exhibited decreased strain, decreased microvascular perfusion, increased LV remodeling index, and increased ECV. Hypertension lead to greater deterioration of LV strain (peak strain-radial, P = 0.002; peak strain-longitudinal, P = 0.006) and LV remodeling index (P = 0.005) in patients with T2DM after adjustment for covariates; however, it did not affect microvascular perfusion (perfusion index, P = 0.469) and ECV (P = 0.375). In multivariable analysis, hypertension and diabetes were independent predictors of reduced LV strain, whereas hypertension is associated with greater impairment of diastolic function (P = 0.009) but not systolic function (P = 0.125) in the context of diabetes, independent of clinical factors and myocardial disorder.
Conclusion
Hypertension in the context of diabetes is significantly associated with LV diastolic function and concentric remodeling; however, it has little effect on systolic function, myocardial microcirculation, or fibrosis independent of covariates, which provide clinical evidence for understanding the pathogenesis of comorbidities and explaining the development of distinct heart failure phenotypes.

Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

J Hypertens: 28 Feb 2021; 39:538-547
Jiang L, Ren Y, Yu H, Guo YK, ... Han PL, Yang ZG
J Hypertens: 28 Feb 2021; 39:538-547 | PMID: 33031176
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Abstract

Influence of Chronic Obstructive Pulmonary Disease on Atrial Mechanics by Speckle Tracking Echocardiography in Patients With Atrial Fibrillation.

Goedemans L, Leung M, van der Bijl P, Abou R, ... Delgado V, Bax JJ
The present study aimed to examine differences in left- and right atrial characteristics between atrial fibrillation (AF) patients with and without chronic obstructive pulmonary disease (COPD). For this, 420 patients (mean age 68 ± 10 years, 73% female) with first diagnosis of AF and baseline echocardiography were included. Of these, 143 COPD patients were compared with 277 patients without COPD matched by age, gender and body surface area. Additionally 38 healthy controls without cardiovascular risk factors, matched for age, were included. For all 3 groups, left atrial (LA) volumes and diameter, LA reservoir strain (LASr), left ventricular ejection fraction (LVEF), right atrial (RA) area and diameter, RA reservoir strain (RASr) and tricuspid annular plane systolic excursion were evaluated on transthoracic echocardiography. Baseline characteristics were similar in patients with and without COPD except for smoking and a history of heart failure (42% vs 11%, p < 0.001 and 48% vs 37%, p = 0.036 for COPD and non-COPD patients, respectively). Also, COPD patients less often used β-blockers (63% vs 75%, p = 0.017). There were no significant differences in LVEF, LA volume and RA area between COPD and non-COPD patients. Compared to the controls, AF patients had impaired LVEF, LASr and RASr. Only RASr was significantly worse in COPD patients as compared to non-COPD patients (15.3% [9.0 to 25.1] vs 19.6% [11.8 to 28.5], p = 0.013). Additionally, a trend towards worse RASr was observed with increasing COPD severity. In conclusion, AF patients with concomitant COPD have more impaired RA function compared to patients without COPD but with similar atrial size and LA function.

Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Mar 2021; 143:60-66
Goedemans L, Leung M, van der Bijl P, Abou R, ... Delgado V, Bax JJ
Am J Cardiol: 14 Mar 2021; 143:60-66 | PMID: 33359195
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Abstract

Left ventricular systolic dysfunction identification using artificial intelligence-augmented electrocardiogram in cardiac intensive care unit patients.

Jentzer JC, Kashou AH, Attia ZI, Lopez-Jimenez F, ... Friedman PA, Noseworthy PA
Background
An artificial intelligence-augmented electrocardiogram (AI-ECG) can identify left ventricular systolic dysfunction (LVSD). We examined the accuracy of AI ECG for identification of LVSD (defined as LVEF ≤40% by transthoracic echocardiogram [TTE]) in cardiac intensive care unit (CICU) patients.
Method
We included unique Mayo Clinic CICU patients admitted from 2007 to 2018 who underwent AI-ECG and TTE within 7 days, at least one of which was during hospitalization. Discrimination of the AI-ECG for LVSD was determined using receiver-operator characteristic curve (AUC) values.
Results
We included 5680 patients with a mean age of 68 ± 15 years (37% females). Acute coronary syndrome (ACS) was present in 55%. LVSD was present in 34% of patients (mean LVEF 48 ± 16%). The AI-ECG had an AUC of 0.83 (95% confidence interval 0.82-0.84) for discrimination of LVSD. Using the optimal cut-off, the AI-ECG had 73%, specificity 78%, negative predictive value 85% and overall accuracy 76% for LVSD. AUC values were higher for patients aged <70 years (0.85 versus 0.80), males (0.84 versus 0.79), patients without ACS (0.86 versus 0.80), and patients who did not undergo revascularization (0.84 versus 0.80).
Conclusions
The AI-ECG algorithm had very good discrimination for LVSD in this critically-ill CICU cohort with a high prevalence of LVSD. Performance was better in younger male patients and those without ACS, highlighting those CICU patients in whom screening for LVSD using AI ECG may be more effective. The AI-ECG might potentially be useful for identification of LVSD in resource-limited settings when TTE is unavailable.

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

Int J Cardiol: 28 Feb 2021; 326:114-123
Jentzer JC, Kashou AH, Attia ZI, Lopez-Jimenez F, ... Friedman PA, Noseworthy PA
Int J Cardiol: 28 Feb 2021; 326:114-123 | PMID: 33152415
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Abstract

Prognostic value of multiple cardiac magnetic resonance imaging parameters in patients with idiopathic dilated cardiomyopathy.

Fu H, Wen L, Xu H, Liu H, ... Yang Z, Guo Y
Purpose
Our study aimed to comprehensively explore efficient prognostic indicators in idiopathic dilated cardiomyopathy (IDCM) patients with reduced left ventricular ejection fraction (LVEF<40%).
Background
Prognostic value of cardiac magnetic resonance(CMR) parameters for IDCM have been inconsistent.
Methods
126 IDCM patients with reduced LVEF (<40%) were retrospectively enrolled. Cardiac function parameters, myocardial strain indices and myocardial fibrosis were evaluated. Laboratory data also were analyzed. The endpoint was a combination of major adverse cardiac events (MACEs), including cardiac death, heart transplantation, and rehospitalization. Prognostic value was evaluated by the Kaplan-Meier method and Cox regression.
Results
During a median follow-up of 31 months, 44 patients experienced MACEs, including 9 deaths, 1 heart transplantation, and 34 rehospitalizations due to heart failure. Univariate and multivariate Cox analyses showed that cardiac function and myocardial strain indexes were not associated with the prognosis of IDCM (all p>0.05). NT-proBNP (HR 1.5, 95%CI: 1.053 to 2.137), Late‑gadolinium enhancement(LGE) mass (HR 1.022, 95%CI: 1.005 to 1.038), and LGE mass/left ventricle mass were significant predictors (HR 1.027, 95%CI: 1.007 to 1.046) for MACEs, all p < 0.05. Besides, poorest prognosis was observed in IDCM patients with positive LGE combined with NT-proBNP (log-rank = 27.261, p ≤ 0.001).
Conclusion
NT-proBNP and extent of LGE were reliable predictors in IDCM patients with reduced LVEF. Additionally, presence of LGE combined with NT-proBNP showed the strongest prognostic value in IDCM with reduced LVEF. Myocardial strain parameters seemed to have no prognostic value in IDCM patients with reduced LVEF.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 14 Feb 2021; 325:89-95
Fu H, Wen L, Xu H, Liu H, ... Yang Z, Guo Y
Int J Cardiol: 14 Feb 2021; 325:89-95 | PMID: 33038407
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Abstract

Modified wire atrial septostomy with a reverse transseptal puncture in an infant: Case report.

Nagatomo Y, Nagata H, Yamamura K, Ohga S
We report a modified technique of wire atrial septostomy (WAS) with a reverse transseptal puncture (TSP) in an infant case of pulmonary atresia with intact ventricular septum. A radiofrequency (RF) wire was advanced to the septum through a 4 Fr pigtail catheter hooked on the left side of atrial septum and RF energy was applied while advancing the wire across the septum. Following that reverse TSP, WAS was performed to cut the septal tissue using a 0.010 microwire and RF wire. The atrial septum defect (ASD) was enlarged to a size of 15 mm. WAS with a reverse TSP could be a useful and safe method to enlarge ASD in infants with congenital heart diseases.

© 2021 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 03 Feb 2021; epub ahead of print
Nagatomo Y, Nagata H, Yamamura K, Ohga S
Catheter Cardiovasc Interv: 03 Feb 2021; epub ahead of print | PMID: 33539042
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Abstract

Association between the E-wave propagation index and left ventricular thrombus formation after ST-elevation myocardial infarction.

Duus LS, Pedersen S, Ravnkilde K, Galatius S, ... Biering-Sørensen T, Olsen FJ
Objective
To explore the association between E-wave propagation index (EPI) as a marker of apical washout and the risk of left ventricular thrombus (LVT) formation in patients with ST-elevation myocardial infarction (STEMI).
Methods
We performed a post-hoc analysis on 364 prospectively enrolled STEMI patients from a single-center. Non-contrast transthoracic echocardiographic examinations were performed a median of 2 days (IQR:1-3 days) after PCI. The endpoint was LVT formation, identified retrospectively. Univariable and multivariable logistic regression was applied to assess the association between EPI and LVT formation. Multivariable adjustments included LVEF, LAD culprit, prior myocardial infarction, heart rate, and early myocardial relaxation velocity. Area under receiver operating characteristic curves (AUC) was used to assess the diagnostic ability.
Results and conclusions
Among 364 patients, 31 (8.5%) developed LVT. The mean age was 62 years, 75% were men, and mean LVEF was 46%. Patients developing LVT had increased heart rate, lower LVEF, impaired GLS, and more frequently had prior myocardial infarction. Variables associated with low values of EPI included, among others, LVEF, LV aneurysm, and GLS. EPI and LVT formation were significantly associated in the univariable model (OR = 1.87 (1.53-2.28), p < 0.001), and EPI showed an AUC of 0.90. After multivariable adjustments, EPI and LVT formation remained significantly associated (OR = 1.79 (1.42-2.27), p < 0.001). Patients with an EPI < 1.0 had a 23 times higher likelihood of LVT formation (OR = 23.41 (10.06-54.49), p < 0.001). EPI and LVT formation are strongly associated in patients with STEMI, with low values of EPI indicating a markedly increased probability of LVT formation.

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

Int J Cardiol: 28 Feb 2021; 326:213-219
Duus LS, Pedersen S, Ravnkilde K, Galatius S, ... Biering-Sørensen T, Olsen FJ
Int J Cardiol: 28 Feb 2021; 326:213-219 | PMID: 33152416
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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, Bairey Merz CN
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 INOCA 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 B.V. All rights reserved.

Int J Cardiol: 14 Mar 2021; 327:25-30
Tamarappoo B, Samuel TJ, Elboudwarej O, Thomson LEJ, ... Nelson MD, Bairey Merz CN
Int J Cardiol: 14 Mar 2021; 327:25-30 | PMID: 33202262
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Abstract

Cardiac magnetic resonance imaging features prognostic information in patients with suspected myocardial infarction with non-obstructed coronary arteries.

Emrich T, Kros M, Schoepf UJ, Geyer M, ... Münzel T, Kreitner KF
Background
To assess the prognostic implications of cardiac magnetic resonance imaging (CMR) in patients with clinical suspicion of myocardial infarction with non-obstructed coronary arteries (MINOCA).
Methods
A total of 145 patients (58 ± 15 years, 97 men) were retrospectively enrolled in this single-center, longitudinal observational study. All patients underwent CMR including cine, edema-sensitive, and late gadolinium enhancement acquisitions, within a median of 3 days after cardiac catheterization. Follow-up was performed by medical records chart review and phone interviews; the median follow-up time was 4.2 years. The primary endpoint was defined as a combination of death, stroke, new onset of congestive heart failure, recurrent hospitalization, or the need for an invasive cardiac procedure.
Results
In 143 (98.6%) cases, CMR revealed the following cardiac pathologies: myocarditis (n = 48, 33.1%), structural cardiomyopathies (n = 40, 27.6%), \"true\" myocardial infarction (n = 22, 15.1%), hypertensive heart disease (n = 19, 13.1%), and Tako-Tsubo cardiomyopathy (n = 14, 9.7%). Only two patients (1.4%) had a normal CMR examination. There were significant prognostic differences between different etiologies, e.g. myocarditis and Tako-Tsubo cardiomyopathy had a more favorable prognosis then structural cardiomyopathies. Age, end-diastolic volume index and time-to-CMR showed significant association with the primary endpoint in multi-variate Cox regression.
Conclusions
CMR performed early after the onset of clinical symptoms allows discrimination between acute myocardial injury from \"true\" MINOCA in patients presenting with chest pain and elevated cardiac biomarkers, thereby helping to identify the underlying pathology in suspected MINOCA and allowing risk stratification based on the established diagnosis. Furthermore, CMR parameters allow for improved prediction of adverse events compared to clinical and laboratory parameters.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 14 Mar 2021; 327:223-230
Emrich T, Kros M, Schoepf UJ, Geyer M, ... Münzel T, Kreitner KF
Int J Cardiol: 14 Mar 2021; 327:223-230 | PMID: 33309758
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Abstract

Cerebral protection in left atrial appendage closure in the presence of appendage thrombosis.

Boccuzzi GG, Montabone A, D\'Ascenzo F, Colombo F, ... Meincke F, Mazzone P
Background
Presence of thrombus in the left atrial appendage (LAA) remains a severe contraindication to the percutaneous left atrial appendage closure procedure (LAAC), due to increased embolic risk. Recently, the experience developed in cerebral protection device in transcatheter aortic valve implantation (TAVI) procedure was translated in LAAC to address this issue.
Aim
To evaluate efficacy and safety of Sentinel cerebral protection system (CPS) in supporting LAAC in real-world patient with persistent LAA thrombus.
Methods and results
The study retrospectively enrolled consecutive patients with non-valvular atrial fibrillation (NVAF) and thrombus in LAA who underwent LAAC supported by Sentinel CPS in seven European high-volume centres. Twenty-seven patients were included with a median age of 69.1 ± 9.7 years old, with median CHA2 DS2 -VASc and HAS-BLEED scores 3 [2-5] and 3 [2.75-4], respectively. Technical and procedural success was achieved in all patients. No periprocedural TIA, stroke, or supra-aortic trunks dissection was recorded.
Conclusions
In this multicenter registry, LAAC supported by Sentinel CPS in patients with LAA persistent thrombus seems to be a safe and efficacious treatment.

© 2020 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 14 Feb 2021; 97:511-515
Boccuzzi GG, Montabone A, D'Ascenzo F, Colombo F, ... Meincke F, Mazzone P
Catheter Cardiovasc Interv: 14 Feb 2021; 97:511-515 | PMID: 32808741
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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, Di Candia A, ... 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 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Mar 2021; 327:68-73
Santoro G, Castaldi B, Cuman M, Di Candia A, ... Pak V, Di Salvo G
Int J Cardiol: 14 Mar 2021; 327:68-73 | PMID: 33220363
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Abstract

Cardiovascular magnetic resonance: What clinicians should know about safety and contraindications.

Barison A, Baritussio A, Cipriani A, Lazzari , ... Dellegrottaglie S, Working Group on Cardiac Magnetic Resonance of the Italian Society of Cardiology
Cardiovascular magnetic resonance (MR) is a multiparametric, non-ionizing, non-invasive imaging technique, which represents the imaging gold standard to study cardiac anatomy, function and tissue characterization. Faced with a wide range of clinical application, in this review we aim to provide a comprehensive guide for clinicians about MR safety, contraindications and image quality. Starting from the physical interactions of the static magnetic fields, gradients and radiofrequencies with the human body, we will describe the most common metal and electronic devices which are allowed (MR-safe), allowed under limited conditions (MR-conditional) or contraindicated (MR-unsafe). Moreover, some conditions potentially affecting image quality and patient comfort will be mentioned, including arrhythmias, claustrophobia, and poor breath-hold capacity. Finally, we will discuss the pharmacodynamics and pharmacokinetics of current gadolinium-based contrast agents, their contraindications and their potential acute and chronic adverse effects, as well as the safety issue concerning the use of vasodilating/inotropic agents in stress cardiac MR.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 07 Feb 2021; epub ahead of print
Barison A, Baritussio A, Cipriani A, Lazzari , ... Dellegrottaglie S, Working Group on Cardiac Magnetic Resonance of the Italian Society of Cardiology
Int J Cardiol: 07 Feb 2021; epub ahead of print | PMID: 33571560
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Abstract

Clinical characteristics and outcomes in patients with echocardiographic left ventricular spontaneous echo contrast.

Liang D, Shi R, Zheng KI, Zhou X, ... Huang W, Shan P
Background
Spontaneous echo contrast (SEC) is a known precursor to thrombus formation and thromboembolic events. This study aims to demonstrate the clinical characteristics and outcomes of patients with left ventricular spontaneous echo contrast (LV-SEC).
Methods
Patients with consecutive echocardiogram performed from October 2009 to September 2019 were enrolled in this retrospective, single-center study. Those with LV-SEC were included, while patients complicated by left ventricular thrombus, with history of infective endocarditis, prosthetic valves, or lost to follow-up were excluded. The clinical endpoint was 1-year thromboembolic events (i.e. stroke and peripheral embolism).
Results
Among 417 patients (mean age 63.5 ± 14.7 years; 86.8% men) with LV-SEC, the incidence of 1-year embolism was 12.9%. In multivariate Cox proportional hazard model, significant risk factors for thromboembolic event were age [hazard ratio (HR) = 1.022, 95% confidence interval (CI): 1.000-1.045], atrial fibrillation (AF) (HR = 2.292, 95% CI: 1.237-4.244), hemoglobin (HR = 1.032, 95% CI: 1.017-1.047), left ventricular ejection fraction (LVEF) (HR = 1.021, 95% CI: 1.002-1.041), and anticoagulant therapy (HR = 0.310, 95% CI: 0.168-0.572). For patients with repeated measurements for echocardiography, D-dimer (HR = 1.137, 95% CI: 1.051-1.231), and LVEF (HR = 0.961, 95% CI: 0.928-0.996) were independently associated with the persistent LV-SEC.
Conclusion
The present study reported a high incidence of 1-year thromboembolic event in patients with LV-SEC. Age, AF, hemoglobin, LVEF were independent risk factors for 1-year embolism and a reduced risk of embolism was observed among patients with anticoagulation therapy. Additionally, D-dimer and LVEF are independently associated with the persistent LV-SEC.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 08 Feb 2021; epub ahead of print
Liang D, Shi R, Zheng KI, Zhou X, ... Huang W, Shan P
Int J Cardiol: 08 Feb 2021; epub ahead of print | PMID: 33577908
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Abstract

Changes in strain parameters at different deterioration levels of left ventricular function: A cardiac magnetic resonance feature-tracking study of patients with left ventricular noncompaction.

Szűcs A, Kiss AR, Gregor Z, Horváth M, ... Merkely B, Vágó H
Background
There is a lack of cardiac MRI information on left ventricular (LV) strain and rotational parameters of left ventricular noncompaction (LVNC) patients with reduced ejection fraction (EF). Thus, we sought to use feature tracking (FT) to describe these changes at different levels of EF deterioration.
Methods
We included 31 adult LVNC patients with reduced LV EF (Group B, EF < 50%) without any comorbidities or concomitant cardiac diseases, 31 age- and sex-matched LVNC patients with good EF (Group A, EF > 50%) and 31 healthy controls. Group B was divided according to LV EF into two subgroups (Group B-1: EF 35-50%, Group B-2: EF < 35%). Their global longitudinal, circumferential (GCS), and radial (GRS) strains; LV segmental strains; LV apical and basal rotation values; and patterns and degree of LV dyssynchrony were measured.
Results
All of the global and mean segmental strain parameters were significantly worse in Groups B, B-1 and B-2 than in Group A and in the controls. The LV mechanical dispersion increased as LV EF decreased. The degree of apical rotation was the highest in the control group, almost the same in Group A and the lowest and in the reverse direction in Group B-2. A rotational pattern, clockwise-directed rigid body rotation (RBR), was found in 39% of the Group B patients, and a counterclockwise-directed RBR was found in 26% of the Group A patients.
Conclusions
The strain values and rotational parameters changed as the EF decreased. These changes affected the global LV, and we did not identify an LVNC-specific strain pattern.

Copyright © 2021 The Author. Published by Elsevier B.V. All rights reserved.

Int J Cardiol: 08 Feb 2021; epub ahead of print
Szűcs A, Kiss AR, Gregor Z, Horváth M, ... Merkely B, Vágó H
Int J Cardiol: 08 Feb 2021; epub ahead of print | PMID: 33577906
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Abstract

Differential and prognostic value of cardiovascular magnetic resonance derived scoring algorithm in cardiac tumors.

Yue P, Xu Z, Wan K, Xie X, ... Sun J, Chen Y
Objectives
To establish a scoring algorithm based on cardiovascular magnetic resonance (CMR) parameters for differentiating between benign and malignant cardiac tumors and for predicting outcome.
Methods
Patients referred for CMR for suspected cardiac tumors were prospectively enrolled. Tumors were categorized as benign or malignant based on pathology, imaging, and clinical information. The CMR protocol included cine, T1-weighted, T2-weighted, first-pass perfusion, and late gadolinium enhancement (LGE) sequences. Variables independently associated with malignancy in the multivariable logistic analysis were used to construct the scoring algorithm, and receiver operating characteristic analyses were used to assess the ability to discriminate malignant from benign tumors. The ability of the score to predict outcome (all-cause mortality) was also assessed by Kaplan-Meier survival analysis.
Results
Among the 105 enrolled patients, 74 had benign and 31 had malignant tumors. In multivariable analysis, the independent predictors of malignant tumors were invasiveness (odds ratio, OR = 11.4, 2 points), irregular border (OR = 5.8, 1 point), and heterogenous LGE (OR 10.6, 2 points). The area under curves (AUC) of the scoring algorithm was 0.912 (cut-off score of 5) and showed significantly higher AUCs than individual variables (all P < 0.05) in differentiating benign and malignant tumors. After median follow-up of 18.2 months, mortality was significantly higher in patients with a score of 5 than in patients with score ≤ 4.
Conclusions
The scoring algorithm based on CMR-detected invasiveness, irregularity of border, and heterogenous LGE is an effective method for differentiating malignant from benign cardiac tumors and for predicting outcome.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 10 Feb 2021; epub ahead of print
Yue P, Xu Z, Wan K, Xie X, ... Sun J, Chen Y
Int J Cardiol: 10 Feb 2021; epub ahead of print | PMID: 33582195
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Abstract

Left Atrial Strain changes in patients with breast cancer during anthracycline therapy.

Laufer-Perl M, Arias O, Dorfman SS, Baruch G, ... Topilsky Y, Kapusta L
Background
Cardiotoxicity has become a significant adverse effect of cancer therapy, with Anthracyclines (ANT) in particular. There is a crucial need for new imaging techniques for the early subclinical detection of cardiotoxic effect. We aimed to evaluate left atrial strain (LAS) changes during ANT therapy and to assess the correlation between LAS and the routine echocardiographic diastolic parameters.
Methods and results
Data were prospectively collected as part of the Israel Cardio-Oncology Registry (ICOR). All female patients with breast cancer, planned for ANT therapy were included. All patients underwent serial echocardiography exams including baseline LAS (before chemotherapy, T1) and shortly after the completion of ANT therapy (T3). LAS was assessed in 3 phases: Reservoir (LASr), Conduit (LASc) and Pump (LASp). Significant reduction in LASr was determined by either a relative reduction of > 10% or an absolute value of <35%. From September 2016 to June 2019, 40 patients were evaluated with a mean Doxorubicin (type of ANT) dose of 237±13.24mg/m2. At T3, significant reduction in LASr was observed among 50% of the patients with a mean LASr reduction from 40.15±6.83 to 36.04±7.73 (p<0.001). LASc showed significant reduction as well (p<0.004) as opposed to LASp (p=0.076). Both LASr and LASc showed significant correlation to the routine diastolic parameters.
Conclusions
LASr and LASc reduction are frequent and occur early in the course of ANT therapy, showing significant correlation to the routine echocardiographic diastolic parameters, which may imply a role in the detection of early cardiotoxicity.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 09 Feb 2021; epub ahead of print
Laufer-Perl M, Arias O, Dorfman SS, Baruch G, ... Topilsky Y, Kapusta L
Int J Cardiol: 09 Feb 2021; epub ahead of print | PMID: 33581179
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Impact:
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 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Mar 2021; 327:63-65
Kang SL, Contreras J, Chaturvedi RR
Int J Cardiol: 14 Mar 2021; 327:63-65 | PMID: 33171168
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Impact:
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: 14 Mar 2021; 327:117-124
Kochav SM, Raita Y, Fifer MA, Takayama H, ... Hasegawa K, Shimada YJ
Int J Cardiol: 14 Mar 2021; 327:117-124 | PMID: 33181159
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Impact:
Abstract

Right ventricular strain in Anderson-Fabry disease.

Lillo R, Graziani F, Panaioli E, Mencarelli E, ... Lanza GA, Crea F
Background
2D speckle tracking echocardiography (2DSTE) is superior to standard echocardiography in the assessment of subtle right ventricle (RV) systolic dysfunction. In this study we aimed to: 1) test the hypothesis that 2DSTE may unveil subtle RV systolic dysfunction in patients with Fabry disease; 2) investigate whether the physiologic difference between the 3-segment (RV-FWS) and the 6-segment (RV-GLS) RV strain (∆RV strain) is preserved in Fabry patients.
Methods and results
Standard echocardiography and 2DSTE were performed in 49 Fabry patients and 49 age- and sex-matched healthy controls. Fabry patients were divided in two groups according to the presence/absence of left ventricular hypertrophy (LVH+: left ventricular wall thickness > 12 mm, 49% of total Fabry patients). RV systolic function assessed by standard echocardiography was normal in the majority of Fabry patients (92%) while RV-GLS and RV-FWS were impaired in about 40%. RV-GLS and RV-FWS were significantly worse in patients LVH+ vs LVH- and vs controls (RV-GLS: LVH+ vs LVH-: -18.4 ± -4.3% vs -23.8 ± -3.1% p˂0.001; LVH+ vs controls: -18.4 ± -4.3% vs -23.9 ± -2.8% p˂0.001; RV-FWS: LVH+ vs LVH-: -21.8 ± -5.3% vs -26.7 ± -3.8% p = 0.002, LVH+ vs controls -21.8 ± -5.3% vs -26.8 ± -3.9% p˂0.001). No difference was found between LVH- patients and controls in both RV-GLS (p = 0.65) and RV-FWS (p = 0.79). ∆RV strain was similar among the groups.
Conclusions
In Fabry cardiomyopathy impaired RV-GLS and RV-FWS is a common finding, while RV strain is preserved in Fabry patients without overt cardiac involvement. The physiologic difference between RV-FWS and RV-GLS is maintained in Fabry patients, regardless of the presence of cardiomyopathy.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 14 Feb 2021; epub ahead of print
Lillo R, Graziani F, Panaioli E, Mencarelli E, ... Lanza GA, Crea F
Int J Cardiol: 14 Feb 2021; epub ahead of print | PMID: 33600844
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Impact:
Abstract

Differentiation of athlete\'s heart and hypertrophic cardiomyopathy by the fractal dimension of left ventricular trabeculae.

Vilades D, Garcia-Moll X, Gomez-Llorente M, Pujadas S, ... Carreras F, Cinca J
Background
Differentiation between exercise induced adaptive myocardial hypertrophy (athlete\'s heart) and hypertrophic cardiomyopathy (HCM) is currently based on echocardiographic and cardiac magnetic resonance (CMR) criteria, but these may be insufficient in patients with subtle phenotype expression. This study aimed to assess whether left ventricular (LV) fractal pattern could permit to differentiate athlete\'s heart from HCM.
Methods
We recruited retrospectively 61 elite marathon runners, 67 patients with HCM, and 33 healthy subjects. A CMR study was performed in all subjects and the LV trabeculae fractal dimension (FD) was measured in end-diastolic frames of each short-axis cine sequence. For group comparison, the ratio of maximal myocardial wall thickness (mMWT)/indexed LV end-diastolic volume (LVED) was determined.
Results
As compared with athletes, patients with HCM had significantly (p < 0.001) greater FD in the LV basal (1.30 ± 0.07 vs. 1.23 ± 0.05) and apical (1.38 ± 0.06 vs. 1.30 ± 0.07) regions and in the whole heart (1.34 ± 0.05 vs. 1.27 ± 0.05). FD increased with age, left atrial area and indexed left ventricular mass (p < 0.05 for all) and correlated negatively with LV and RV end-diastolic volumes (p < 0.05 each). The addition of whole heart FD to the ratio of maximal myocardial wall thickness/indexed LVEDV lead to an improvement in the ability to discriminate HCM with a net reclassification index (NRI) of 71%.
Conclusions
The FD regional distribution of the LV trabeculae differentiates patients with athlete\'s heart from patients with HCM. The addition of whole heart FD to the mMWT/indexed LVEDV ratio improves the predictive capacity of the model to differentiate both entities.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 19 Feb 2021; epub ahead of print
Vilades D, Garcia-Moll X, Gomez-Llorente M, Pujadas S, ... Carreras F, Cinca J
Int J Cardiol: 19 Feb 2021; epub ahead of print | PMID: 33621621
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Impact:
Abstract

Intervendor agreement of right ventricular global longitudinal strain in children.

Aly D, Ramlogan S, France R, Schmidt S, ... Goudar SP, Forsha D
Background
Right ventricular (RV) global longitudinal strain (GLS) emerged as an important technique for clinical evaluation of RV function. The routine application of RVGLS in pediatrics remains limited by the lack of data on agreement between vendors. We investigated the intervendor agreement of RVGLS between the two commonly used analysis vendors in pediatrics hypothesizing that RVGLS has good intervendor agreement although it is likely lower than intravendor agreement (inter and intraobserver reproducibility).
Methods
Seventy infants and children with normal cardiac anatomy and varying ventricular function were included after prospectively obtaining RV focused 4-chamber apical images on the Vivid E95. Images were analyzed for RVGLS at acquired frame rates in EchoPAC (GE) and TomTec (TTacq) and in the compressed DICOM format in TomTec (TT30). Intraclass correlation coefficients (ICC) and Bland-Altman plots tested intervendor agreement and intravendor reproducibility.
Results
RVGLS measurements were equally feasible using TT and EchoPAC analysis (92%). There was good-excellent agreement of RVGLS between TT and EchoPAC analysis with a relatively higher ICC for GE-TTacq (0.85) than for GE-TT30 (0.75), and significantly higher agreement in patients with abnormal RV function (0.7-0.9) than those with normal function (0.4-0.6). Intra and interobserver reproducibility of RVGLS was excellent (ICC 0.74 - 0.96). Heart rate (HR) ≥ 100 bpm and acquisition frame rate/HR ≤0.7 were associated with diminished agreement, especially when compressed data were involved.
Conclusion
RVGLS analyzed by EchoPAC and TT show good agreement, especially when analyzed at the acquisition frame rates and in the setting of abnormal RV function. Otherwise, RVGLS should ideally be analyzed using the same vendor and intervendor comparisons should be undertaken with caution particularly if data are in a compressed format.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Feb 2021; epub ahead of print
Aly D, Ramlogan S, France R, Schmidt S, ... Goudar SP, Forsha D
J Am Soc Echocardiogr: 05 Feb 2021; epub ahead of print | PMID: 33561494
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Impact:
Abstract

The predictive role of combined cardiac and lung ultrasound in Coronavirus Disease 2019.

Szekely Y, Lichter Y, Hochstadt A, Taieb P, ... Banai S, Topilsky Y
Background:
and objectives
We aimed to evaluate sonographic features that may aid in risk stratification and propose a focused cardiac and lung ultrasound (LUS) algorithm in patients with COVID-19
Methods:
Two hundred consecutive hospitalized patients with COVID-19 underwent comprehensive clinical and echocardiographic examination, as well as LUS, irrespective of clinical indication, within 24 hours of admission as part of a prospective predefined protocol. Assessment included calculation of the Modified Early Warning Score (MEWS), left ventricular (LV) systolic and diastolic function, hemodynamic and right ventricular (RV) assessment and a calculated LUS score. We performed outcome analysis to identify echocardiographic and LUS predictors of mortality or the composite event of mortality or need for invasive mechanical ventilation, and to assess their adjunctive value on top of clinical parameters and MEWS.
Results
A simplified echocardiographic risk score comprised of LV ejection fraction< 50% combined with TAPSE< 18 mm, was associated with mortality (p=0.0002) and with the composite event (p=0.0001). Stepwise analyses evaluating echocardiographic and LUS parameters on top of existing clinical risk scores showed that addition of TAPSE and SVI improved prediction of mortality when added to clinical variables but not when added to MEWS. Once echocardiography was added, and patients re-categorized as high risk only if having both high risk MEWS, and high-risk cardiac features, the specificity increased from 63% to 87%, positive predictive value from 28% to 48% and accuracy improved from 66% to 85%. Although LUS was not associated with incremental risk prediction for mortality above clinical and echocardiographic criteria, it improved prediction of need for invasive mechanical ventilation.
Conclusions
In hospitalized patients with COVID-19, a very limited echocardiographic exam is sufficient for outcome prediction. The addition of echocardiography in patients with high risk MEWS score decreases the rate of falsely identifying patients as high risk to die, and may improve resource allocation in case of high patient load.
Background


Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 07 Feb 2021; epub ahead of print
Szekely Y, Lichter Y, Hochstadt A, Taieb P, ... Banai S, Topilsky Y
J Am Soc Echocardiogr: 07 Feb 2021; epub ahead of print | PMID: 33571647
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Impact:
Abstract

Exercise intolerance in HFpEF: arterial stiffness and abnormal left ventricular hemodynamic responses during exercise.

Zern EK, Ho JE, Panah LG, Lau ES, ... Nayor M, Lewis GD
Background
Arterial stiffness is thought to contribute to the pathophysiology of heart failure with preserved ejection fraction (HFpEF). We sought to examine arterial stiffness in HFpEF and hypertension and investigate associations of arterial and left ventricular hemodynamic responses to exercise.
Methods
A total of 385 symptomatic individuals with EF ≥ 50% underwent upright cardiopulmonary exercise testing with invasive hemodynamic assessment of arterial stiffness and load (aortic augmentation pressure, augmentation index, systemic vascular resistance index, total arterial compliance index, effective arterial elastance index, and pulse pressure amplification) at rest and during incremental exercise. An abnormal hemodynamic response to exercise was defined as a steep increase in pulmonary capillary wedge pressure relative to cardiac output (∆PCWP/∆CO > 2 mmHg/L/min). We compared rest and exercise measures between HFpEF and hypertension in multivariable analyses.
Results
Among 188 HFpEF participants (age 61±13, 56% women), resting arterial stiffness parameters were worse compared to 94 hypertensive participants (age 55 ± 15, 52% women); these differences were accentuated during exercise in HFpEF (all p≤0.0001). Among all participants, exercise measures of arterial stiffness correlated with worse ∆PCWP/∆CO. Specifically, a 1-SD higher exercise augmentation pressure was associated with 2.15-fold greater odds of abnormal LV hemodynamic response (95% CI 1.52-3.05, p<0.001). Further, exercise measures of systemic vascular resistance index, elastance index, and pulse pressure amplification correlated with lower peak VO2.
Conclusions
Exercise accentuates elevated arterial stiffness in HFpEF, which in turn correlate with left ventricular hemodynamic responses. Unfavorable ventricular-vascular interactions during exercise in HFpEF may contribute to exertional intolerance and inform future therapeutic interventions.

Copyright © 2021. Published by Elsevier Inc.

J Card Fail: 25 Feb 2021; epub ahead of print
Zern EK, Ho JE, Panah LG, Lau ES, ... Nayor M, Lewis GD
J Card Fail: 25 Feb 2021; epub ahead of print | PMID: 33647476
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Impact:
Abstract

Three-dimensional cardiac print assisted percutaneous closure of left ventricular pseudoaneurysm in patient with Behçet\'s disease.

Quimby DL, Ford J, Tanner GJ, Mencer N, Decker S, Matar F
Spontaneous left ventricular pseudoaneurysms are very rare and can have catastrophic consequences if unrecognized. A case of combined spontaneous left ventricular aneurysm and pseudoaneurysm in Behcet\'s disease (BD) has been reported. The case emphasizes advanced techniques for percutaneous closure of the defects with the use of an ex-vivo three-dimensional cardiac printed model as a tool to facilitate the procedure.

© 2021 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 25 Feb 2021; epub ahead of print
Quimby DL, Ford J, Tanner GJ, Mencer N, Decker S, Matar F
Catheter Cardiovasc Interv: 25 Feb 2021; epub ahead of print | PMID: 33638270
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Impact:
Abstract

Short-term direct oral anticoagulation or dual antiplatelet therapy following left atrial appendage closure in patients with relative contraindications to chronic anticoagulation therapy.

Faroux L, Cruz-González I, Arzamendi D, Freixa X, ... O\'Hara G, Rodés-Cabau J
Background
Biological data suggest that anticoagulation would be more effective than dual antiplatelet therapy (DAPT) to reduce the thrombotic risk following left atrial appendage closure (LAAC). This study sought to assess the safety and efficacy of direct oral anticoagulation (DOAC) versus DAPT immediately post-LAAC.
Methods
Multicenter study including 592 consecutive patients with relative contraindication to chronic anticoagulation who underwent LAAC and received either DAPT or DOAC for 1-3 months. Each patient receiving DOAC was matched with 2 patients on DAPT based on propensity-score (propensity-matched population of 285 patients). Outcomes recorded were death, stroke, non-procedural related severe bleeding, serious adverse event (SAE: composite of death, stroke, bleeding) and early (within 3 months post-LAAC) device-related thrombosis (DRT).
Results
Early outcomes (within 3-month post-LAAC) did not significantly differ between groups, but a numerically higher rate of early death (3.7% vs. 1.1%), non-procedural related severe bleeding (7.4% vs. 3.2%), and SAE (11.1% vs. 5.3%) were observed in patients receiving DAPT. After a median follow-up of 22 (8-38) months, similar outcomes were observed in DAPT and DOAC groups regarding death (HR: 1.18; 95% CI: 0.58-2.37; p = 0.652), stroke (HR: 1.01; 95% CI: 0.22-5.45; p = 0.908), non-procedural related severe bleeding (HR: 1.68; 95% CI: 0.69-4.12; p = 0.257), and SAE (HR: 1.28; 95% CI: 0.73-2.24; p = 0.383). DRT was identified in 4 patients (2.6%) receiving DAPT versus 0 patient receiving DOAC (p = 0.162).
Conclusions
Short-term DOAC following LAAC in patients with contraindications to chronic anticoagulation was safe and tended to associate with a lower rate of SAE and DRT compared to DAPT.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 25 Feb 2021; epub ahead of print
Faroux L, Cruz-González I, Arzamendi D, Freixa X, ... O'Hara G, Rodés-Cabau J
Int J Cardiol: 25 Feb 2021; epub ahead of print | PMID: 33647365
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Impact:
Abstract

A burden of sarcomere gene variants in fetal-onset patients with left ventricular noncompaction.

Hirono K, Hata Y, Ozawa SW, Toda T, ... Ichida F, for LVNC study collaborators
Background
Left ventricular noncompaction (LVNC) is a hereditary cardiomyopathy, associated with high morbidity and mortality, but the role of genetics in cases of fetal-onset has not been fully evaluated. The goal of this study was to identify the genetic background in LVNC fetal-onset patients using next-generation sequencing (NGS).
Methods
Thirty-three fetal-onset Japanese probands with LVNC (20 males and 13 females) were enrolled. In the enrolled patients, 81 genes associated with cardiomyopathy were screened using next-generation sequencing (NGS) retrospectively.
Results
Twenty-three patients had congestive heart failure (CHF), and six patients had arrhythmias. Prominent trabeculations were mostly observed in lateral LV, posterior LV, and apex of LV in patients with LVNC. Twelve died; three patients experienced intrauterine death or termination of pregnancy. Overall, 15 variants were found among eight genes in 16 patients. Seven variants were detected in MYH7 and two in TPM1. Sarcomere gene variants accounted for 75.0%. A multivariable proportional hazards model revealed that CHF at diagnosis and a higher ratio of the noncompacted layer/compacted layer in the LV posterior wall were independent risk factors for death in LVNC fetal-onset patients (odds ratio = 4.26 × 106 and 1.36 × 108, p = 0.0075 and 0.0005, respectively).
Conclusions
The present study is the first report focusing on genetic background combined with clinical features in LVNC fetal-onset patients using NGS. Sarcomere variants were most commonly identified in fetal-onset patients, and greater attention should be paid to fetal-onset patients with LVNC having prominent trabeculations in the LV because they are more likely to develop CHF.

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

Int J Cardiol: 31 Mar 2021; 328:122-129
Hirono K, Hata Y, Ozawa SW, Toda T, ... Ichida F, for LVNC study collaborators
Int J Cardiol: 31 Mar 2021; 328:122-129 | PMID: 33309763
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Impact:
Abstract

Long term clinical outcomes associated with CMR quantified isolated left ventricular non-compaction in adults.

Femia G, Zhu D, Choudhary P, Ross SB, ... Semsarian C, Puranik R
Background
Left ventricular non-compaction (LVNC) is a complex clinical condition with several diagnostic criteria but no diagnostic gold standard. We aimed to evaluate our thresholding technique in a group of patients with LVNC and assess the risk of major adverse cardiovascular and cerebrovascular events (MACCE).
Methods
We retrospectively analyzed cardiac magnetic resonance (CMR) scans of patients with Petersen criteria LVNC and quantified noncompacted myocardial mass. We assessed the association of noncompacted myocardial mass, CMR derived LV volumetric parameters and late gadolinium enhancement (LGE) to MACCE including cardiac death, cardiac transplantation, sustained ventricular tachycardia/ventricular fibrillation (VT/VF) and ischemic stroke. Patients with known genetic mutations and cardiovascular disease were excluded.
Results
98 patients with LVNC were included (55 males,56.7%); 17(17.3%) patients had impaired LV function and five (5.1%) had LGE. Patients with impaired LV function had more end-systolic noncompacted mass (61.9 g±22.4 vs. 38.1 g±15.8, p < 0.001) and larger end-systolic noncompacted to total myocardial mass (44%±9 vs. 36%±12, p = 0.003). At 78 months follow-up [interquartile range(IQR) 66-90], MACCE occurred in 11(11.3%) patients; nine(81.8%) had impaired LV function and two(18.2%) had LGE. Impaired LV function and LV LGE were predictors of MACCE (HR = 35.6, 95% CI = 7.65-165.21, p < 0.001 and HR = 16.2, 95% CI = 4.54-57.84, p < 0.001) whereas noncompacted mass were not.
Conclusion
Noncompacted mass was not an independent predictor of major adverse events but in patients with impaired LV function and/or LV LGE, the risk of MACCE was high. These results highlight the importance of including LV volumetrics and scar in the assessment of patients with LV noncompaction.

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

Int J Cardiol: 31 Mar 2021; 328:235-240
Femia G, Zhu D, Choudhary P, Ross SB, ... Semsarian C, Puranik R
Int J Cardiol: 31 Mar 2021; 328:235-240 | PMID: 33309759
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Impact:
Abstract

Primary pericardial angiosarcoma: A case report.

Li W, Han L, Ye Z
Primary pericardial angiosarcoma is a rare malignant cardiac neoplasm with early metastasis and poor prognosis. There are currently no guidelines or effective therapeutic strategies. Here we report a case of a 22-year-old man who presented with chest pain, suffocation and transient syncope over the course of 4 months. Further workup showed a large mass in the right pericardium, histopathologic examination revealed angiosarcoma. The patient subsequently received a total of 8 cycles of chemotherapy (paclitaxel and doxorubicin). This patient has an overall survival of 1 year to date. The current examination methods and reported cases revealed that early detection of primary pericardial angiosarcoma with imaging examinations is critical for prognosis.



J Nucl Cardiol: 07 Feb 2021; epub ahead of print
Li W, Han L, Ye Z
J Nucl Cardiol: 07 Feb 2021; epub ahead of print | PMID: 33559092
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Impact:
Abstract

Pattern of arterial inflammation and inflammatory markers in people living with HIV compared with uninfected people.

Taglieri N, Bonfiglioli R, Bon I, Malosso P, ... Re MC, Galié N
Study design
To compare arterial inflammation (AI) between people living with HIV (PLWH) and uninfected people as assessed by 18F-Fluorodeoxyglucose (18F-FDG)-positron emission tomography (PET).
Methods
We prospectively enrolled 20 PLWH and 20 uninfected people with no known cardiovascular disease and at least 3 traditional cardiovascular risk factors. All patients underwent 18F-FDG-PET/computed tomography (CT) of the thorax and neck. Biomarkers linked to inflammation and atherosclerosis were also determined. The primary outcome was AI in ascending aorta (AA) measured as mean maximum target-to-background ratio (TBRmax). The independent relationships between HIV status and both TBRmax and biomarkers were evaluated by multivariable linear regression adjusted for body mass index, creatinine, statin therapy, and atherosclerotic cardiovascular 10-year estimated risk (ASCVD).
Results
Unadjusted mean TBRmax in AA was slightly higher but not statistically different (P = .18) in PLWH (2.07; IQR 1.97, 2.32]) than uninfected people (2.01; IQR 1.85, 2.16]). On multivariable analysis, PLWH had an independent risk of increased mean log-TBRmax in AA (coef = 0.12; 95%CI 0.01,0.22; P = .032). HIV infection was independently associated with higher values of interleukin-10 (coef = 0.83; 95%CI 0.34, 1.32; P = .001), interferon-γ (coef. = 0.90; 95%CI 0.32, 1.47; P = .003), and vascular cell adhesion molecule-1 (VCAM-1) (coef. = 0.75; 95%CI: 0.42, 1.08, P < .001).
Conclusions
In patients with high cardiovascular risk, HIV status was an independent predictor of increased TBRmax in AA. PLWH also had an increased independent risk of IFN-γ, IL-10, and VCAM-1 levels.



J Nucl Cardiol: 09 Feb 2021; epub ahead of print
Taglieri N, Bonfiglioli R, Bon I, Malosso P, ... Re MC, Galié N
J Nucl Cardiol: 09 Feb 2021; epub ahead of print | PMID: 33569752
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Impact:
Abstract

Relation between myocardial blood flow and cardiac events in diabetic patients with suspected coronary artery disease and normal myocardial perfusion imaging.

Assante R, Mainolfi CG, Zampella E, Gaudieri V, ... Cuocolo A, Acampa W
Background
We assessed the prognostic value of structural abnormalities and coronary vasodilator function in diabetic patients referred to a PET/CT for suspected coronary artery disease (CAD).
Methods
We studied 451 diabetics and 451 nondiabetics without overt CAD and normal myocardial perfusion. Myocardial blood flow (MBF) was computed from the dynamic rest and stress imaging. Myocardial flow reserve (MFR) was defined as ratio of hyperemic to baseline MBF and was considered reduced when < 2.
Results
During a mean follow-up of 44 months 33 events occurred. Annualized event rate (AER) was higher in diabetic than nondiabetic patients (1.4% vs 0.3%, P < .001). Diabetic patients with reduced MFR had higher AER compared to those with preserved MFR (3.3% vs 0.4%, P  < .001). At Cox analysis, age, BMI and reduced MFR were independent predictors of events in diabetic patients. Patients with diabetes and reduced MFR had lower event-free survival compared to nondiabetic patients and MFR < 2 (P < .001). Event-free survival was similar in patients with diabetes and normal MFR and those without diabetes and reduced MFR.
Conclusions
Diabetic patients with reduced MFR had higher AER and lower event-free survival compared to those with preserved MFR and to nondiabetic patients.



J Nucl Cardiol: 17 Feb 2021; epub ahead of print
Assante R, Mainolfi CG, Zampella E, Gaudieri V, ... Cuocolo A, Acampa W
J Nucl Cardiol: 17 Feb 2021; epub ahead of print | PMID: 33599942
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Impact:
Abstract

Incremental value of epicardial fat volume to coronary artery calcium score and traditional risk factors for predicting myocardial ischemia in patients with suspected coronary artery disease.

Yu W, Zhang F, Liu B, Wang J, ... Xu Y, Wang Y
Background
Epicardial fat volume (EFV) has been reported to be associated with coronary artery disease (CAD). CAD is the leading cause of myocardial ischemia and myocardial ischemia is closely related to major adverse cardiovascular events. We hypothesized that EFV could provide incremental value to traditional risk factors and coronary artery calcium score (CACS) in predicting myocardial ischemia in Chinese patients with suspected CAD.
Methods
We retrospectively studied 204 Chinese patients with suspected CAD who underwent single-photon emission computerized tomography-myocardial perfusion imaging (SPECT-MPI) combined with computed tomography (CT). Pericardial contours were manually defined, and EFV was automatically calculated. A reversible perfusion defect with summed difference score (SDS) ≥ 2 was defined as myocardial ischemia.
Results
The myocardial ischemia group had higher EFV than normal MPI group (137.80 ± 34.95cm3 vs. 106.63 ± 29.10 cm3, P < .001). In multivariable logistic regression analysis, high EFV was significantly associated with myocardial ischemia [odds ratio (OR): 8.30, 95% CI: 3.72-18.49, P < .001]. Addition of EFV to CACS and traditional risk factors could predict myocardial ischemia more effectively, with larger AUC .82 (P < .001), positive net reclassification index .14 (P = .04) and integrated discrimination improvement .14 (P < .001). The bootstrap resampling method (times = 500) was used to internally validation and calculate the 95% confidence interval (CI) of the AUC (95% CI .75-.87). The calibration curve for the probability of myocardial ischemia demonstrated good agreement between prediction and observation.
Conclusions
In Chinese patients with suspected CAD, EFV was significantly associated with myocardial ischemia, and improved prediction of myocardial ischemia above traditional risk factors and CACS.



J Nucl Cardiol: 18 Feb 2021; epub ahead of print
Yu W, Zhang F, Liu B, Wang J, ... Xu Y, Wang Y
J Nucl Cardiol: 18 Feb 2021; epub ahead of print | PMID: 33608856
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Impact:
Abstract

The prevalence of image degradation due to motion in rest-stress rubidium-82 imaging on a SiPM PET-CT system.

Armstrong IS, Memmott MJ, Hayden C, Arumugam P
Background
Motion of the heart is known to affect image quality in cardiac PET. The prevalence of motion blurring in routine cardiac PET is not fully appreciated due to challenges identifying subtle motion artefacts. This study utilizes a recent prototype Data-Driven Motion Correction (DDMC) algorithm to generate corrected images that are compared with non-corrected images to identify visual differences in relative rubidium-82 perfusion images due to motion.
Methods
300 stress and 300 rest static images were reconstructed with DDMC and without correction (NMC). The 600 DDMC/NMC image pairs were assigned Visual Difference Score (VDS). The number of non-diagnostic images were noted. A \"Dwell Fraction\" (DF) was derived from the data to quantify motion and predict image degradation.
Results
Motion degradation (VDS = 1 or 2) was evident in 58% of stress images and 33% of rest images. Seven NMC images were non-diagnostic-these originated from six studies giving a 2% rate of non-diagnostic studies due to motion. The DF metric was able to effectively predict image degradation. The DDMC heart identification and tracking was successful in all images.
Conclusion
Motion degradation is present in almost half of all relative perfusion images. The DDMC algorithm is a robust tool for predicting, assessing and correcting image degradation.



J Nucl Cardiol: 18 Feb 2021; epub ahead of print
Armstrong IS, Memmott MJ, Hayden C, Arumugam P
J Nucl Cardiol: 18 Feb 2021; epub ahead of print | PMID: 33608851
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Impact:
Abstract

Longitudinal analysis of atherosclerotic plaques evolution: an F-NaF PET/CT study.

Fiz F, Piccardo A, Morbelli S, Bottoni G, ... Bagnasco M, Sambuceti G
Purpose
18F-NaF-PET/CT can detect mineral metabolism within atherosclerotic plaques. To ascertain whether their 18F-NaF uptake purports progression, this index was compared with subsequent morphologic evolution.
Methods
71 patients underwent two consecutive 18F-NaF-PET/CTs (PET1/PET2). In PET1, non-calcified 18F-NaF hot spots were identified in the abdominal aorta. Their mean/max HU was compared with those of a non-calcified control region (CR) and with corresponding areas in PET2. A target-to-background ratio (TBR), mean density (HU), and calcium score (CS) were calculated on calcified atherosclerotic plaques in PET1 and compared with those in PET2. A VOI including the entire abdominal aorta was drawn; mean TBR and total CS were calculated on PET1 and compared with those PET2.
Results
Hot spots in PET1 (N = 179) had a greater HU than CR (48 ± 8 vs 37 ± 9, P < .01). Mean hot spots HU increased to 59 ± 12 in PET2 (P < .001). New calcifications appeared at the hot spots site in 73 cases (41%). Baseline atherosclerotic plaque\'s (N = 375) TBR was proportional to percent HU and CS increase (P < .01 for both). Aortic CS increased (P < .001); the whole-aorta TBR in PET1 correlated with the CS increase between the baseline and the second PET/CT (R = .63, P < .01).
Conclusions
18F-NaF-PET/CT depicts the early stages of plaques development and tracks their evolution over time.



J Nucl Cardiol: 24 Feb 2021; epub ahead of print
Fiz F, Piccardo A, Morbelli S, Bottoni G, ... Bagnasco M, Sambuceti G
J Nucl Cardiol: 24 Feb 2021; epub ahead of print | PMID: 33630243
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Impact:
Abstract

Left ventricular mass on positron emission tomography: Validation against cardiovascular magnetic resonance.

Malahfji M, Ahmed AI, Han Y, Jung AK, ... Mahmarian JJ, Al-Mallah MH
Background
Left ventricular hypertrophy (LVH) is an important clinical finding that is independently associated with mortality and cardiovascular events. We aimed to assess the interstudy variability of LV mass quantitation between PET and CMR.
Methods
Patients who underwent both PET and CMR within 1 year were identified from prospective institutional registries. LV mass on PET was compared against LV mass on CMR using several statistical measures of agreement.
Results
A total of 105 patients (mean age 60 ± 14 years, 67.6% male) were included. The median (interquartile range, IQR) duration between CMR and PET was 47 (11-154) days. The median (IQR) LV mass values were 168.0 g (126.0-202.0) on CMR and 174.0 g (150.0-212.0) with PET (absolute mean difference 29.42 ± 25.3). There was a good correlation (Spearman ρ = 0.81, P < 0.001; Intraclass Correlation Coefficient 0.78, 95% CI 0.70-0.85, P < 0.001) with moderate limits of agreement (95% limits of agreement - 63.78 to 83.7.) Results were consistent, albeit with moderate correlation, in subgroups of patients with LVH, in patients with myocardial infarction, in patients with LV ejection fraction < 50%, and those with limited image quality. LV mass on PET tended to be underestimated at high values compared to CMR.
Conclusion
We demonstrate good correlation and reproducibility of LV mass quantitation by PET against the reference standard of CMR across a wide range of normal and diseased hearts with a tendency of PET to underestimate mass at higher mass values.



J Nucl Cardiol: 23 Feb 2021; epub ahead of print
Malahfji M, Ahmed AI, Han Y, Jung AK, ... Mahmarian JJ, Al-Mallah MH
J Nucl Cardiol: 23 Feb 2021; epub ahead of print | PMID: 33629247
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Impact:
Abstract

Improved risk-stratification in heart failure patients with mid-range to severe abnormalities of QRS duration and systolic function using mechanical dyssynchrony assessed by myocardial perfusion-gated SPECT.

Doi T, Nakata T, Noto T, Mita T, Yuda S, Hashimoto A
Background
The use of left ventricular mechanical dyssynchrony (LVMD), which has been reported to be responsible for unfavorable outcomes, might improve conventional risk-stratification by clinical indices including QRS duration (QRSd) and systolic dysfunction in patients with heart failure (HF).
Methods and results
Following measurements of 12-lead QRSd and left ventricular ejection fraction (LVEF), three-dimensional (3-D) LVMD was evaluated as a standard deviation (phase SD) of regional mechanical systolic phase angles by gated myocardial perfusion imaging in 829 HF patients. Patients were followed up for a mean period of 37 months with a primary endpoint of lethal cardiac events (CEs). In an overall multivariate Cox proportional hazards model, phase SDs were identified as significant prognostic determinants independently. The patients were divided into 4 groups by combining with the cut-off values of LVEF (35% and 50%) and QRSd (130 ms and 150 ms). The groups with lower LVEF and prolonged QRSd more frequently had CEs than did the other groups. Patient groups with LVEF < 35% and with 35% ≦ LVEF < 50% were differentiated into low-risk and high-risk categories by using an optimal phase SD cut-off value of both QRSd thresholds.
Conclusions
3-D LVMD can risk-stratify HF patients with mid-range as well as severe abnormalities of QRSd and systolic dysfunction.



J Nucl Cardiol: 23 Feb 2021; epub ahead of print
Doi T, Nakata T, Noto T, Mita T, Yuda S, Hashimoto A
J Nucl Cardiol: 23 Feb 2021; epub ahead of print | PMID: 33629244
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Impact:
Abstract

Global Left Ventricular Myocardial Work Efficiency and Long-Term Prognosis in Patients After ST-Segment-Elevation Myocardial Infarction.

Lustosa RP, Butcher SC, van der Bijl P, El Mahdiui M, ... Bax JJ, Delgado V
Background
Left ventricular (LV) global longitudinal strain has demonstrated incremental prognostic value over LV ejection fraction in patients with ST-segment-elevation myocardial infarction. However, LV global longitudinal strain does not take into consideration the effect of afterload. Novel speckle-tracking echocardiographic indices of myocardial work integrate blood pressure measurements (afterload) with LV global longitudinal strain. The present study aimed to investigate the prognostic value of global LV myocardial work efficiency (GLVMWE; reflecting LV performance) obtained from pressure-strain loops with echocardiography in patients with ST-segment-elevation myocardial infarction.
Methods
A total of 507 ST-segment-elevation myocardial infarction patients (mean age, 61±11 years; 76% men) were retrospectively analyzed. LV ejection fraction and GLVMWE were measured by transthoracic echocardiography within 48 hours of admission. GLVMWE was defined as the ratio of constructive work divided by the sum of constructive and wasted work in all LV segments and expressed as a percentage. Spline curve analysis was used to define the association between reduced GLVMWE and all-cause death.
Results
After a median follow-up of 80 months (interquartile range, 67-97 months), 40 (8%) patients died. Patients with reduced GLVMWE (<86%) showed higher cumulative rates of all-cause mortality (17.5% versus 4.7%; log-rank P<0.001) in comparison with patients with preserved GLVMWE (≥86%). Reduced GLVMWE (<86%) showed an independent association with all-cause mortality (hazard ratio, 3.167 [95% CI, 1.679-5.972]; P<0.001).
Conclusions
Reduced GLVMWE (<86%) measured by transthoracic echocardiography within 48 hours of admission in ST-segment-elevation myocardial infarction patients is associated with worse long-term survival.



Circ Cardiovasc Imaging: 01 Mar 2021:CIRCIMAGING120012072; epub ahead of print
Lustosa RP, Butcher SC, van der Bijl P, El Mahdiui M, ... Bax JJ, Delgado V
Circ Cardiovasc Imaging: 01 Mar 2021:CIRCIMAGING120012072; epub ahead of print | PMID: 33653082
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Impact:
Abstract

Influence of patient motion on quantitative accuracy in cardiac O-water positron emission tomography.

Nordström J, Harms HJ, Kero T, Sörensen J, Lubberink M
Background
Patient motion is a common problem during cardiac PET. The purpose of the present study was to investigate to what extent motions influence the quantitative accuracy of cardiac 15O-water PET/CT and to develop a method for automated motion detection.
Method
Frequency and magnitude of motion was assessed visually using data from 50 clinical 15O-water PET/CT scans. Simulations of 4 types of motions with amplitude of 5 to 20 mm were performed based on data from 10 scans. An automated motion detection algorithm was evaluated on clinical and simulated motion data. MBF and PTF of all simulated scans were compared to the original scan used as reference.
Results
Patient motion was detected in 68% of clinical cases by visual inspection. All observed motions were small with amplitudes less than half the LV wall thickness. A clear pattern of motion influence was seen in the simulations with a decrease of myocardial blood flow (MBF) in the region of myocardium to where the motion was directed. The perfusable tissue fraction (PTF) trended in the opposite direction. Global absolute average deviation of MBF was 3.1% ± 1.8% and 7.3% ± 6.3% for motions with maximum amplitudes of 5 and 20 mm, respectively. Automated motion detection showed a sensitivity of 90% for simulated motions ≥ 10 mm but struggled with the smaller (≤ 5 mm) simulated (sensitivity 45%) and clinical motions (accuracy 48%).
Conclusion
Patient motion can impair the quantitative accuracy of MBF. However, at typically occurring levels of patient motion, effects are similar to or only slightly larger than inter-observer variability, and downstream clinical effects are likely negligible.



J Nucl Cardiol: 01 Mar 2021; epub ahead of print
Nordström J, Harms HJ, Kero T, Sörensen J, Lubberink M
J Nucl Cardiol: 01 Mar 2021; epub ahead of print | PMID: 33655448
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Impact:
Abstract

Effect of temporal sampling protocols on myocardial blood flow measurements using Rubidium-82 PET.

Koenders SS, van Dijk JD, Jager PL, Mouden M, ... Slump CH, van Dalen JA
Background
A variety of temporal sampling protocols is used worldwide to measure myocardial blood flow (MBF). Both the length and number of time frames in these protocols may alter MBF and myocardial flow reserve (MFR) measurements. We aimed to assess the effect of different clinically used temporal sampling protocols on MBF and MFR quantification in Rubidium-82 (Rb-82) PET imaging.
Methods
We retrospectively included 20 patients referred for myocardial perfusion imaging using Rb-82 PET. A literature search was performed to identify appropriate sampling protocols. PET data were reconstructed using 14 selected temporal sampling protocols with time frames of 5-10 seconds in the first-pass phase and 30-120 seconds in the tissue phase. Rest and stress MBF and MFR were calculated for all protocols and compared to the reference protocol with 26 time frames.
Results
MBF measurements differed (P ≤ 0.003) in six (43%) protocols in comparison to the reference protocol, with mean absolute relative differences up to 16% (range 5%-31%). Statistically significant differences were most frequently found for protocols with tissue phase time frames < 90 seconds. MFR did not differ (P ≥ 0.11) for any of the protocols.
Conclusions
Various temporal sampling protocols result in different MBF values using Rb-82 PET. MFR measurements were more robust to different temporal sampling protocols.



J Nucl Cardiol: 01 Mar 2021; epub ahead of print
Koenders SS, van Dijk JD, Jager PL, Mouden M, ... Slump CH, van Dalen JA
J Nucl Cardiol: 01 Mar 2021; epub ahead of print | PMID: 33655444
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Impact:
Abstract

Pulmonary ridge coverage and device-related thrombosis after left atrial appendage occlusion.

Freixa X, Cepas-Guillen P, Flores-Umanzor E, Regueiro A, ... Sitges M, Sabaté M
Aims
The aim of this study was 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 into two groups according to the PR coverage. A total of 147 patients were included. Among these, the 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 between the groups. The rate of procedural major adverse events was 3% (only major bleedings and/or vascular access complications). No device embolisation, cardiac tamponade or in-hospital mortality was observed. After a mean follow-up of 1.77±2.2 years, the annualised ischaemic stroke and major bleeding rate was 1.3%/year and 6.5%/year, respectively, without differences between groups. At follow-up, patients with a covered PR presented a lower incidence of device-related thrombosis (DRT) (1%) than those with an 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 between covered PR and uncovered PR patients.



EuroIntervention: 04 Feb 2021; 16:e1288-e1294
Freixa X, Cepas-Guillen P, Flores-Umanzor E, Regueiro A, ... Sitges M, Sabaté M
EuroIntervention: 04 Feb 2021; 16:e1288-e1294 | PMID: 33164895
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Impact:
Abstract

The acute effects of an ultramarathon on biventricular function and ventricular arrhythmias in master athletes.

Cavigli L, Zorzi A, Spadotto V, Gismondi A, ... Cameli M, D\'Ascenzi F
Aims
Endurance sports practice has significantly increased over the last decades, with a growing proportion of participants older than 40 years. Although the benefits of moderate regular exercise are well known, concerns exist regarding the potential negative effects induced by extreme endurance sport. The aim of this study was to analyse the acute effects of an ultramarathon race on the electrocardiogram (ECG), biventricular function, and ventricular arrhythmias in a population of master athletes.
Methods and results
Master athletes participating in an ultramarathon (50 km, 600 m of elevation gain) with no history of heart disease were recruited. A single-lead ECG was recorded continuously from the day before to the end of the race. Echocardiography and 12-lead resting ECG were performed before and at the end of the race. The study sample consisted of 68 healthy non-professional master athletes. Compared with baseline, R-wave amplitude in V1 and QTc duration were higher after the race (P < 0.001). Exercise-induced isolated premature ventricular beats were observed in 7% of athletes; none showed non-sustained ventricular tachycardia before or during the race. Left ventricular ejection fraction, global longitudinal strain (GLS), and twisting did not significantly differ before and after the race. After the race, no significant differences were found in right ventricular inflow and outflow tract dimensions, fractional area change, s\', and free wall GLS.
Conclusion 
In master endurance athletes running an ultra-marathon, exercise-induced ventricular dysfunction, or relevant ventricular arrhythmias was not detected. These results did not confirm the hypothesis of a detrimental acute effect of strenuous exercise on the heart.

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

Eur Heart J Cardiovasc Imaging: 04 Feb 2021; epub ahead of print
Cavigli L, Zorzi A, Spadotto V, Gismondi A, ... Cameli M, D'Ascenzi F
Eur Heart J Cardiovasc Imaging: 04 Feb 2021; epub ahead of print | PMID: 33544827
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Impact:
Abstract

Traditional markers of cardiac toxicity fail to detect marked reductions in cardiorespiratory fitness among cancer patients undergoing anti-cancer treatment.

Howden EJ, Foulkes S, Dillon HT, Bigaran A, ... Costello B, La Gerche A
Aims
Left ventricular ejection fraction (LVEF) is standard of care for evaluating chemotherapy-associated cardiotoxicity, although global longitudinal strain (GLS) offers advantages. However, neither change in LVEF or GLS has been associated with short-term symptoms, functional capacity, or long-term heart failure (HF) risk. We sought to determine whether an integrative measure of cardiovascular function (VO2peak) that is strongly associated with HF risk would be more sensitive to cardiac damage induced by cancer treatment than LVEF, GLS, or cardiac biomarkers.
Methods and results
Patients (n = 206, 53 ± 13 years, 35% male) scheduled to commence anti-cancer treatment completed assessment prior to, and within 6 months after therapy. Changes in echocardiographic measures of LV function (LVEF, GLS), cardiac biomarkers (troponin and BNP), and cardiorespiratory fitness (VO2peak) were measured. LV function was normal prior to treatment (LVEF 61 ± 5%; GLS -19.4 ± 2.1), but VO2peak was only 88 ± 26% of age-predicted. After treatment, VO2peak was reduced by 7 ± 15% (equivalent of 7 years normal ageing, P < 0.0001) and the rates of functional disability (defined as VO2peak ≤ 18 mL/min/kg) almost doubled (15% vs. 26%, P = 0.016). In contrast, small, reductions in LVEF (59 ± 5% vs. 58 ± 5%, P = 0.03) and GLS (-19.4 ± 2.1 vs. -18.9 ± 2.2, P = 0.002) and an increase in troponin levels (4.0 ± 6.9 vs. 26.4 ± 26.2 ng/mL, P < 0.0001) were observed.
Conclusion
Anti-cancer treatment is associated with marked reductions in functional capacity that occur independent of reductions in LVEF and GLS. The assessment of VO2peak prior to, and following treatment may be a more sensitive means of identifying patients at increased risk of HF.

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

Eur Heart J Cardiovasc Imaging: 04 Feb 2021; epub ahead of print
Howden EJ, Foulkes S, Dillon HT, Bigaran A, ... Costello B, La Gerche A
Eur Heart J Cardiovasc Imaging: 04 Feb 2021; epub ahead of print | PMID: 33543256
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Impact:
Abstract

Cardiac computed tomography in cardio-oncology: an update on recent clinical applications.

Rosmini S, Aggarwal A, Chen DH, Conibear J, ... Guha A, Ghosh AK
Chemotherapy and radiotherapy have drastically improved cancer survival, but they can result in significant short- and long-term cardiovascular complications, most commonly heart failure from chemotherapy, whilst radiotherapy increases the risk of premature coronary artery disease (CAD), valve, and pericardial diseases. Cardiac computed tomography (CT) with calcium scoring has a role in screening asymptomatic patients for premature CAD, cardiac CT angiography (CTCA) allows the identification of significant CAD, also in the acute settings where concerns exist towards invasive angiography. CTCA integrates the diagnostic work-up and guides surgical/percutaneous management of valvular heart diseases and allows the assessment of pericardial conditions, including detection of effusion and pericardial calcification. It is a widely available and fast imaging modality that allows a one-step evaluation of CAD, myocardial, valvular, and pericardial disease. This review aims to provide an update on its current use and accompanying evidence-base for cardiac CT in the management of cardio-oncology 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: 07 Feb 2021; epub ahead of print
Rosmini S, Aggarwal A, Chen DH, Conibear J, ... Guha A, Ghosh AK
Eur Heart J Cardiovasc Imaging: 07 Feb 2021; epub ahead of print | PMID: 33555007
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Impact:
Abstract

Blood flow characteristics after aortic valve neocuspidization in paediatric patients: a comparison with the Ross procedure.

Secinaro A, Milano EG, Ciancarella P, Trezzi M, ... Albanese SB, Carotti A
Aims
The aortic valve (AV) neocuspidization (Ozaki procedure) is a novel surgical technique for AV disease that preserves the natural motion and cardiodynamics of the aortic root. In this study, we sought to evaluate, by 4D-flow magnetic resonance imaging, the aortic blood flow characteristics after AV neocuspidization in paediatric patients.
Methods and results
Aortic root and ascending aorta haemodynamics were evaluated in a population of patients treated with the Ozaki procedure; results were compared with those of a group of patients operated with the Ross technique. Cardiovascular magnetic resonance studies were performed at 1.5 T using a 4D flow-sensitive sequence acquired with retrospective electrocardiogram-gating and respiratory navigator. Post-processing of 4D-flow analysis was performed to calculate flow eccentricity and wall shear stress. Twenty children were included in this study, 10 after Ozaki and 10 after Ross procedure. Median age at surgery was 10.7 years (range 3.9-16.5 years). No significant differences were observed in wall shear stress values measured at the level of the proximal ascending aorta between the two groups. The analysis of flow patterns showed no clear association between eccentric flow and the procedure performed. The Ozaki group showed just a slightly increased transvalvular maximum velocity.
Conclusion
Proximal aorta flow dynamics of children treated with the Ozaki and the Ross procedure are comparable. Similarly to the Ross, Ozaki technique restores a physiological laminar flow pattern in the short-term follow-up, with the advantage of not inducing a bivalvular disease, although further studies are warranted to evaluate its long-term results.

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

Eur Heart J Cardiovasc Imaging: 06 Feb 2021; epub ahead of print
Secinaro A, Milano EG, Ciancarella P, Trezzi M, ... Albanese SB, Carotti A
Eur Heart J Cardiovasc Imaging: 06 Feb 2021; epub ahead of print | PMID: 33550364
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Impact:
Abstract

Pacemaker lead-associated tricuspid regurgitation in patients with or without pre-existing right ventricular dilatation.

Riesenhuber M, Spannbauer A, Gwechenberger M, Pezawas T, ... Hengstenberg C, Gyongyosi M
Background
Transcatheter tricuspid valve intervention became an option for pacemaker lead-associated tricuspid regurgitation. This study investigated the progression of tricuspid regurgitation (TR) in patients with or without pre-existing right ventricular dilatation (RVD) undergoing pacemaker implantation.
Methods
Patients were included if they had implantation of transtricuspid pacemaker lead and completed echocardiography before and after implantation. The cohort was divided in patients with and without RVD (cut-off basal RV diameter ≥ 42 mm). TR was graded in none/mild, moderate, and severe. Worsening of one grade was defined as progression. Survival analyses were plotted for 10 years.
Results
In total, 990 patients were analyzed (24.5% with RVD). Progression of TR occurred in 46.1% of patients with RVD and in 25.6% of patients without RVD (P < 0.001). Predictors for TR progression were RV dilatation (OR 2.04; 95% CI 1.27-3.29; P = 0.003), pre-existing TR (OR 4.30; 95% CI 2.51-7.38; P < 0.001), female sex (OR 1.68; 95% CI 1.16-2.43; P = 0.006), single RV lead (OR 1.67; 95% CI 1.09-2.56; P = 0.018), mitral regurgitation (OR 2.08; 95% CI 1.42-3.05; P < 0.001), and enlarged left atrium (OR 1.98; 95% CI 1.07-3.67; P = 0.03). Survival-predictors were pacemaker lead-associated TR (HR 1.38; 95% CI 1.04-1.84; P = 0.028), mitral regurgitation (HR 1.34; 95% CI 1.02-1.77; P = 0.034), heart failure (HR 1.75; 95% CI 1.31-2.33; P < 0.001), kidney disease (HR 1.62; 95% CI 1.25-2.11; P < 0.001), and age ≥ 80 years (HR 2.84; 95% CI 2.17-3.71; P < 0.001).
Conclusions
Patients with RVD receiving pacemaker suffered from increased TR progression, leading to decreased survival.



Clin Res Cardiol: 09 Feb 2021; epub ahead of print
Riesenhuber M, Spannbauer A, Gwechenberger M, Pezawas T, ... Hengstenberg C, Gyongyosi M
Clin Res Cardiol: 09 Feb 2021; epub ahead of print | PMID: 33566185
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Impact:
Abstract

Impact of sinus rhythm versus atrial fibrillation on left ventricular remodeling after transcatheter aortic valve replacement.

Ledwoch J, Fröhlich C, Olbrich I, Poch F, ... Kupatt C, Hoppmann P
Aims
Atrial fibrillation (AF) is associated with increased mortality after transcatheter aortic valve replacement (TAVR). Cerebrovascular complications and bleeding events associated with anticoagulation therapy are discussed to be possible causes for this increased mortality. The present study sought to assess whether AF is associated with impaired left ventricular (LV) reverse remodeling representing another possible mechanism for poor outcome.
Methods
All patients who underwent TAVR in our institution and had 1-year echocardiography follow-up were included. LV mass index (LVMI) at baseline and follow-up as well as LVMI change at 1 year were assessed with respect to the presence of AF (either at baseline or during hospitalization after TAVR) and sinus rhythm (SR).
Results
A total of 213 patients (n = 95 in AF; n = 118 in SR) were enrolled in the present study. Patients with AF had higher LVMI at 1 year compared to those with SR (173 ± 61 g/m2 vs. 154 ± 55 g/m2; p = 0.02) and they showed lower relative LVMI change at 1 year (- 2 ± 28% vs. - 9 ± 29%; p = 0.04). In linear regression analysis, AF was independently associated with relative LVMI change (regression coefficient ß 0.076 [95% CI 0.001-0.150]; p = 0.04). With respect to clinical outcome depending on AF and LVMI regression, the Kaplan-Meier estimated event-free of death or cardiac rehospitalization at 3 years was lowest among patients with AF and no LVMI regression.
Conclusions
The present study identified a significant association of AF with changes in LVMI after TAVR, which was also shown to be associated with clinical outcome.



Clin Res Cardiol: 09 Feb 2021; epub ahead of print
Ledwoch J, Fröhlich C, Olbrich I, Poch F, ... Kupatt C, Hoppmann P
Clin Res Cardiol: 09 Feb 2021; epub ahead of print | PMID: 33566184
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Impact:
Abstract

The structural heart disease interventional imager rationale, skills and training: a position paper of the European Association of Cardiovascular Imaging.

Agricola E, Ancona F, Brochet E, Donal E, ... Cosyns B, Edvardsen T
Percutaneous therapeutic options for an increasing variety of structural heart diseases (SHD) have grown dramatically. Within this context of continuous expansion of devices and procedures, there has been increased demand for physicians with specific knowledge, skills, and advanced training in multimodality cardiac imaging. As a consequence, a new subspecialty of \'Interventional Imaging\' for SHD interventions and a new dedicated professional figure, the \'Interventional Imager\' with specific competencies has emerged. The interventional imager is an integral part of the heart team and plays a central role in decision-making throughout the patient pathway, including the appropriateness and feasibility of a procedure, pre-procedural planning, intra-procedural guidance, and post-procedural follow-up. However, inherent challenges exist to develop a training programme for SHD imaging that differs from traditional cardiovascular imaging pathways. The purpose of this document is to provide the standard requirements for the training in SHD imaging, as well as a starting point for an official certification process for SHD interventional imager.

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

Eur Heart J Cardiovasc Imaging: 09 Feb 2021; epub ahead of print
Agricola E, Ancona F, Brochet E, Donal E, ... Cosyns B, Edvardsen T
Eur Heart J Cardiovasc Imaging: 09 Feb 2021; epub ahead of print | PMID: 33564848
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Impact:
Abstract

The Leiden Convention coronary coding system: translation from the surgical to the universal view.

Koppel CJ, Vliegen HW, Bökenkamp R, Ten Harkel ADJ, ... Gittenberger-de Groot AC, Jongbloed MRM
Aims
The Leiden Convention coronary coding system structures the large variety of coronary anatomical patterns; isolated and in congenital heart disease. It is widely used by surgeons but not by cardiologists as the system uses a surgeons\' cranial view. Since thoracic surgeons and cardiologists work closely together, a coronary coding system practical for both disciplines is mandatory. To this purpose, the \'surgical\' coronary coding system was adapted to an \'imaging\' system, extending its applicability to different cardiac imaging techniques.
Methods and results
The physician takes place in the non-facing sinus of the aortic valve, oriented with the back towards the pulmonary valve, looking outward from the sinus. From this position, the right-hand sinus is sinus 1, and the left-hand sinus is sinus 2. Next, a clockwise rotation is adopted starting at sinus 1 and the encountered coronary branches described. Annotation of the normal anatomical pattern is 1R-2LCx, corresponding to the \'surgical\' coding system. The \'imaging\' coding system was made applicable for Computed Tomography (CT), Magnetic Resonance Imaging (MRI), echocardiography, and coronary angiography, thus facilitating interdisciplinary use. To assess applicability in daily clinical practice, images from different imaging modalities were annotated by cardiologists and cardiology residents and results scored. The average score upon evaluation was 87.5%, with the highest scores for CT and MRI images (average 90%).
Conclusion
The imaging Leiden Convention is a coronary coding system that unifies the annotation of coronary anatomy for thoracic surgeons, cardiologists, and radiologists. Validation of the coding system shows it can be easily and reliably applied in clinical practice.

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

Eur Heart J Cardiovasc Imaging: 14 Feb 2021; epub ahead of print
Koppel CJ, Vliegen HW, Bökenkamp R, Ten Harkel ADJ, ... Gittenberger-de Groot AC, Jongbloed MRM
Eur Heart J Cardiovasc Imaging: 14 Feb 2021; epub ahead of print | PMID: 33585887
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Impact:
Abstract

Strain by speckle tracking echocardiography correlates with electroanatomic scar location and burden in ischaemic cardiomyopathy.

Trivedi SJ, Campbell T, Stefani LD, Thomas L, Kumar S
Aims
Ventricular tachycardia (VT) in ischaemic cardiomyopathy (ICM) originates from scar, identified as low-voltage areas with invasive high-density electroanatomic mapping (EAM). Abnormal myocardial deformation on speckle tracking strain echocardiography can non-invasively identify scar. We examined if regional and global longitudinal strain (GLS) can localize and quantify low-voltage scar identified with high-density EAM.
Methods and results
We recruited 60 patients, 40 ICM patients undergoing VT ablation and 20 patients undergoing ablation for other arrhythmias as controls. All patients underwent an echocardiogram prior to high-density left ventricular (LV) EAM. Endocardial bipolar and unipolar scar location and percentage were correlated with regional and multilayer GLS. Controls had normal GLS and normal bipolar and unipolar voltages. There was a strong correlation between endocardial and mid-myocardial longitudinal strain and endocardial bipolar scar percentage for all 17 LV segments (r = 0.76-0.87, P < 0.001) in ICM patients. Additionally, indices of myocardial contraction heterogeneity, myocardial dispersion (MD), and delta contraction duration (DCD) correlated with bipolar scar percentage. Endocardial and mid-myocardial GLS correlated with total LV bipolar scar percentage (r = 0.83; 0.82, P < 0.001 respectively), whereas epicardial GLS correlated with epicardial bipolar scar percentage (r = 0.78, P < 0.001). Endocardial GLS -9.3% or worse had 93% sensitivity and 82% specificity for predicting endocardial bipolar scar >46% of LV surface area.
Conclusions
Multilayer strain analysis demonstrated good linear correlations with low-voltage scar by invasive EAM. Validation studies are needed to establish the utility of strain as a non-invasive tool for quantifying scar location and burden, thereby facilitating mapping and ablation of VT.

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

Eur Heart J Cardiovasc Imaging: 14 Feb 2021; epub ahead of print
Trivedi SJ, Campbell T, Stefani LD, Thomas L, Kumar S
Eur Heart J Cardiovasc Imaging: 14 Feb 2021; epub ahead of print | PMID: 33585879
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Impact:
Abstract

Determinants of paravalvular leakage following transcatheter aortic valve replacement in patients with bicuspid and tricuspid aortic stenosis.

Kim WK, Bhumimuang K, Renker M, Fischer-Rasokat U, ... Nef H, Hamm CW
Aims
Paravalvular leakage (PVL) after transcatheter aortic valve replacement (TAVR) is a common complication in patients with bicuspid aortic valve (BAV). However, predictors and mechanisms of PVL are not well understood in this subset. The aim of this study was to analyse determinants and mechanisms of PVL in BAV and tricuspid aortic valve (TAV).
Methods and results
Of the 2394 consecutive patients undergoing transfemoral TAVR using new-generation valves at our centre, we identified 242 cases with BAV. To adjust for baseline differences, we performed 3 : 1 propensity score matching (TAVPS  n = 726). We analysed the aortic root anatomy and calcification as well as the number, circumferential distribution, and predilection sites of PVL using pre-procedural multidetector computed tomography and post-TAVR echocardiography. In the matched cohort, the incidence of PVL ≥mild (BAV 51.9% vs. TAVPS 51.7%; P = 0.955) and PVL ≥moderate (BAV 5.0% vs. TAVPS 3.7%; P = 0.393), the circumferential distribution, and independent predictors were similar between BAV and TAVPS. Both the presence of peri-annular calcium chunks or LVOT calcification were highly associated with PVL in BAV and TAVPS patients, whereas in BAV patients neither the presence of a calcium bridge nor the volume of its calcification was related to PVL. Notably, the spatial localization of these lesions did not necessarily match the circumferential leak position.
Conclusion
The incidence, circumferential distribution, predilection sites, and predictors of PVL were similar in matched population of BAV and TAVPS patients undergoing transfemoral TAVR using new-generation devices. These novel findings suggest a common underlying mechanism of PVL in both entities.

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

Eur Heart J Cardiovasc Imaging: 13 Feb 2021; epub ahead of print
Kim WK, Bhumimuang K, Renker M, Fischer-Rasokat U, ... Nef H, Hamm CW
Eur Heart J Cardiovasc Imaging: 13 Feb 2021; epub ahead of print | PMID: 33582771
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Impact:
Abstract

Quantified coronary total plaque volume from computed tomography angiography provides superior 10-year risk stratification.

Deseive S, Kupke M, Straub R, Stocker TJ, ... Hadamitzky M, Hausleiter J
Aims 
Automated coronary total plaque volume (TPV) quantification derived from coronary computed tomographic angiography (CTA) datasets provide exact and reliable assessment of calcified and non-calcified coronary atherosclerosis burden. The aim of this analysis was to investigate the long-term predictive value of TPV.
Methods and results 
TPV was quantified in 1577 patients undergoing coronary CTA and cardiovascular events were collected during 10.5 years (interquartile range 6.0-11.4) of follow-up. The study endpoint comprised cardiac death and acute coronary syndrome and occurred in 59 (3.7%) patients. Coronary TPV provided additive prognostic value over clinical risk assessed with the Morise Score and coronary artery disease severity (rise in C-index from 0.744 to 0.769, P = 0.03). A category-based reclassification approach combining the Morise Score and TPV revealed superior risk stratification (categorical net reclassification improvement: 0.48 with 95% CI 0.13-0.68, P < 0.001) and resulted in reclassification of 800 (51%) patients compared with the Morise Score alone. The 10-year risk for the study endpoint was 0.6% (95% CI 0-1.3) for patients classified as low risk (n = 807), 4.8% (95% CI 2.4-7.2) for patients at intermediate risk (n = 400), and 10.3% (95% CI 6.6-13.9) for patients at high risk (n = 370) using the combined reclassification approach.
Conclusion 
Quantification of TPV from coronary CTA permits an improved 10-year cardiovascular risk stratification.

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 Feb 2021; 22:314-321
Deseive S, Kupke M, Straub R, Stocker TJ, ... Hadamitzky M, Hausleiter J
Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:314-321 | PMID: 32793952
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Impact:
Abstract

Left ventricular myocardial work in the culprit vessel territory and impact on left ventricular remodelling in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention.

Lustosa RP, Fortuni F, van der Bijl P, Goedemans L, ... Delgado V, Knuuti J
Aims
Adverse left ventricular (LV) remodelling after ST-segment elevation myocardial infarction (STEMI) is associated with poor outcome. Global and regional LV myocardial work (LVMW) derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure recordings could provide information for prediction of LV remodelling after STEMI. The aim of the study was to assess the predictive value of global and regional LVMW for LV remodelling before discharge in patients with STEMI.
Methods and results
Three-hundred and fifty STEMI patients treated with primary percutaneous coronary intervention (PCI) were included [265 men (76%), mean age: 61 ± 10 years]. Clinical variables, conventional echocardiographic parameters, global and regional measures of myocardial work index (MWI), and myocardial work efficiency were recorded before discharge. The primary endpoint was early LV remodelling defined as increase in LV end-diastolic volume (LVEDV) ≥20% at 3 months after STEMI. Eighty-seven patients (25%) showed early LV remodelling. The global and regional LVMW in the culprit territory were significantly lower in patients with early LV remodelling. Peak troponin I (OR 1.109, 95% CI 1.046-1.177; P = 0.001), LVEDV (OR 0.972, 95% CI 0.959-0.984; P < 0.001) and regional MWI in the culprit vessel territory (OR 0.602, 95% CI 0.383-0.945; P = 0.027) were independently associated with early LV remodelling.
Conclusion
In STEMI patients treated with primary PCI and optimal medical therapy, the regional cardiac work index in the culprit vessel territory before discharge is independently associated with early adverse LV remodelling.

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 Feb 2021; 22:339-347
Lustosa RP, Fortuni F, van der Bijl P, Goedemans L, ... Delgado V, Knuuti J
Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:339-347 | PMID: 32642755
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Impact:
Abstract

Pericardial adipose tissue, cardiac structures, and cardiovascular risk factors in school-age children.

Toemen L, Santos S, Roest AAW, Vernooij MW, ... Gaillard R, Jaddoe VWV
Aims 
We examined the associations of pericardial adipose tissue with cardiac structures and cardiovascular risk factors in children.
Methods and results 
We performed a cross-sectional analysis in a population-based cohort study among 2892 children aged 10 years (2404 normal weight and 488 overweight/obese). Pericardial adipose tissue mass was estimated by magnetic resonance imaging (MRI) and indexed on height3. Left ventricular mass (LVM) and left ventricular mass-to-volume ratio (LMVR) were estimated by cardiac MRI. Cardiovascular risk factors included android adipose tissue percentage obtained by Dual-energy X-ray absorptiometry, blood pressure and glucose, insulin, cholesterol, and triglycerides concentrations. Adverse outcomes were defined as values above the 75 percentile. Median pericardial adipose tissue index was 3.6 (95% range 1.6-7.1) among normal weight and 4.7 (95% range 2.0-8.9) among overweight children. A one standard deviation (1 SD) higher pericardial adipose tissue index was associated with higher LMVR [0.06 standard deviation scores, 95% confidence interval (CI) 0.02-0.09], increased odds of high android adipose tissue [odd ratio (OR) 2.08, 95% CI 1.89-2.29], high insulin concentrations (OR 1.17, 95% CI 1.06-1.30), an atherogenic lipid profile (OR 1.22, 95% CI 1.11-1.33), and clustering of cardiovascular risk factors (OR 1.56, 95% CI 1.36-1.79). Pericardial adipose tissue index was not associated with LVM, blood pressure, and glucose concentrations. The associations showed largely the same directions but tended to be weaker among normal weight than among overweight children.
Conclusion 
Pericardial adipose tissue is associated with cardiac adaptations and cardiovascular risk factors already in childhood in both normal weight and overweight children.

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

Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:307-313
Toemen L, Santos S, Roest AAW, Vernooij MW, ... Gaillard R, Jaddoe VWV
Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:307-313 | PMID: 32154869
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Impact:
Abstract

The echocardiographic ratio tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure predicts short-term adverse outcomes in acute pulmonary embolism.

Lyhne MD, Kabrhel C, Giordano N, Andersen A, ... Zheng H, Dudzinski DM
Aims
Right ventricular (RV) failure causes death from acute pulmonary embolism (PE), due to a mismatch between RV systolic function and increased RV afterload. We hypothesized that an echocardiographic ratio of this mismatch [RV systolic function by tricuspid annular plane systolic excursion (TAPSE) divided by pulmonary arterial systolic pressure (PASP)] would predict adverse outcomes better than each measurement individually, and would be useful for risk stratification in intermediate-risk PE.
Methods and results
This was a retrospective analysis of a single academic centre Pulmonary Embolism Response Team registry from 2012 to 2019. All patients with confirmed PE and a formal transthoracic echocardiogram performed within 2 days were included. All echocardiograms were analysed by an observer blinded to the outcome. The primary endpoint was a 7-day composite outcome of death or haemodynamic deterioration. Secondary outcomes were 7- and 30-day all-cause mortality. A total of 627 patients were included; 135 met the primary composite outcome. In univariate analysis, the TAPSE/PASP was associated with our primary outcome [odds ratio = 0.028, 95% confidence interval (CI) 0.010-0.087; P < 0.0001], which was significantly better than either TAPSE or PASP alone (P = 0.017 and P < 0.0001, respectively). A TAPSE/PASP cut-off value of 0.4 was identified as the optimal value for predicting adverse outcome in PE. TAPSE/PASP predicted both 7- and 30-day all-cause mortality, while TAPSE and PASP did not.
Conclusion
A combined echocardiographic ratio of RV function to afterload is superior in prediction of adverse outcome in acute intermediate-risk PE. This ratio may improve risk stratification and identification of the patients that will suffer short-term deterioration after intermediate-risk PE.

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 Feb 2021; 22:285-294
Lyhne MD, Kabrhel C, Giordano N, Andersen A, ... Zheng H, Dudzinski DM
Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:285-294 | PMID: 33026070
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Abstract

Prognostic durability of coronary computed tomography angiography.

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

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

Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:331-338
Chow BJW, Yam Y, Small G, Wells GA, ... Ruddy TD, Hossain A
Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:331-338 | PMID: 33111135
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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: 21 Feb 2021; 22:251-258
Raisi-Estabragh Z, Harvey NC, Neubauer S, Petersen SE
Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:251-258 | PMID: 33164079
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Impact:
Abstract

Measurement accuracy of prototype non-contrast, compressed sensing-based, respiratory motion-resolved whole heart cardiovascular magnetic resonance angiography for the assessment of thoracic aortic dilatation: comparison with computed tomography angiography.

Yacoub B, Stroud RE, Piccini D, Schoepf UJ, ... Suranyi P, Varga-Szemes A
Background
Patients with thoracic aortic dilatation who undergo annual computed tomography angiography (CTA) are subject to repeated radiation and contrast exposure. The purpose of this study was to evaluate the feasibility of a non-contrast, respiratory motion-resolved whole-heart cardiovascular magnetic resonance angiography (CMRA) technique against reference standard CTA, for the quantitative assessment of cardiovascular anatomy and monitoring of disease progression in patients with thoracic aortic dilatation. 
Methods:
Twenty-four patients (68.6 ± 9.8 years) with thoracic aortic dilatation prospectively underwent clinical CTA and research 1.5T CMRA between July 2017 and November 2018. Scans were repeated in 15 patients 1 year later. A prototype free-breathing 3D radial balanced steady-state free-precession whole-heart CMRA sequence was used in combination with compressed sensing-based reconstruction. Area, circumference, and diameter measurements were obtained at seven aortic levels by two experienced and two inexperienced readers. In addition, area and diameter measurements of the cardiac chambers, pulmonary arteries and pulmonary veins were also obtained. Agreement between the two modalities was assessed with intraclass correlation coefficient (ICC) analysis, Bland-Altman plots and scatter plots.
Results
Area, circumference and diameter measurements on a per-level analysis showed good or excellent agreement between CTA and CMRA (ICCs > 0.84). Means of differences on Bland-Altman plots were: area 0.0 cm2 [- 1.7; 1.6]; circumference 1.0 mm [- 10.0; 12.0], and diameter 0.6 mm [- 2.6; 3.6]. Area and diameter measurements of the left cardiac chambers showed good agreement (ICCs > 0.80), while moderate to good agreement was observed for the right chambers (all ICCs > 0.56). Similar good to excellent inter-modality agreement was shown for the pulmonary arteries and veins (ICC range 0.79-0.93), with the exception of the left lower pulmonary vein (ICC < 0.51). Inter-reader assessment demonstrated mostly good or excellent agreement for both CTA and CMRA measurements on a per-level analysis (ICCs > 0.64). Difference in maximum aortic diameter measurements at baseline vs follow up showed excellent agreement between CMRA and CTA (ICC = 0.91).
Conclusions
The radial whole-heart CMRA technique combined with respiratory motion-resolved reconstruction provides comparable anatomical measurements of the thoracic aorta and cardiac structures as the reference standard CTA. It could potentially be used to diagnose and monitor patients with thoracic aortic dilatation without exposing them to radiation or contrast media.



J Cardiovasc Magn Reson: 07 Feb 2021; 23:7
Yacoub B, Stroud RE, Piccini D, Schoepf UJ, ... Suranyi P, Varga-Szemes A
J Cardiovasc Magn Reson: 07 Feb 2021; 23:7 | PMID: 33557887
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Impact:
Abstract

Electrocardiogram-less, free-breathing myocardial extracellular volume fraction mapping in small animals at high heart rates using motion-resolved cardiovascular magnetic reesonance multitasking: a feasibility study in a heart failure with preserved ejection fraction rat model.

Han P, Zhang R, Wagner S, Xie Y, ... Christodoulou AG, Li D
Background
Extracellular volume fraction (ECV) quantification with cardiovascular magnetic resonance (CMR) T1 mapping is a powerful tool for the characterization of focal or diffuse myocardial fibrosis. However, it is technically challenging to acquire high-quality T1 and ECV maps in small animals for preclinical research because of high heart rates and high respiration rates. In this work, we developed an electrocardiogram (ECG)-less, free-breathing ECV mapping method using motion-resolved CMR Multitasking on a 9.4 T small animal CMR system. The feasibility of characterizing diffuse myocardial fibrosis was tested in a rat heart failure model with preserved ejection fraction (HFpEF).
Methods
High-salt fed rats diagnosed with HFpEF (n = 9) and control rats (n = 9) were imaged with the proposed ECV Multitasking technique. A 25-min exam, including two 4-min T1 Multitasking scans before and after gadolinium injection, were performed on each rat. It allows a cardiac temporal resolution of 20 ms for a heart rate of ~ 300 bpm. Myocardial ECV was calculated from the hematocrit (HCT) and fitted T1 values of the myocardium and the blood pool. Masson\'s trichrome stain was used to measure the extent of fibrosis. Welch\'s t-test was performed between control and HFpEF groups.
Results
ECV was significantly higher in the HFpEF group (22.4% ± 2.5% vs. 18.0% ± 2.1%, P = 0.0010). A moderate correlation between the ECV and the extent of fibrosis was found (R = 0.59, P = 0.0098).
Conclusions
Motion-resolved ECV Multitasking CMR can quantify ECV in the rat myocardium at high heart rates without ECG triggering or respiratory gating. Elevated ECV found in the HFpEF group is consistent with previous human studies and well correlated with histological data. This technique has the potential to be a viable imaging tool for myocardial tissue characterization in small animal models.



J Cardiovasc Magn Reson: 10 Feb 2021; 23:8
Han P, Zhang R, Wagner S, Xie Y, ... Christodoulou AG, Li D
J Cardiovasc Magn Reson: 10 Feb 2021; 23:8 | PMID: 33568177
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Impact:
Abstract

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

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

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

Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:273-281
Kotecha T, Monteagudo JM, Martinez-Naharro A, Chacko L, ... Rakhit R, Fontana M
Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:273-281 | PMID: 33188683
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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, PARADIGM Investigators
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: 21 Feb 2021; 22:322-330
Bax AM, van Rosendael AR, Ma X, van den Hoogen IJ, ... Shaw LJ, PARADIGM Investigators
Eur Heart J Cardiovasc Imaging: 21 Feb 2021; 22:322-330 | PMID: 33215192
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Impact:
Abstract

Fully quantitative mapping of abnormal aortic velocity and wall shear stress direction in patients with bicuspid aortic valves and repaired coarctation using 4D flow cardiovascular magnetic resonance.

van Ooij P, Farag ES, Blanken CPS, Nederveen AJ, ... Planken RN, Boekholdt SM
Background
Helices and vortices in thoracic aortic blood flow measured with 4D flow cardiovascular magnetic resonance (CMR) have been associated with aortic dilation and aneurysms. Current approaches are semi-quantitative or when fully quantitative based on 2D plane placement. In this study, we present a fully quantitative and three-dimensional approach to map and quantify abnormal velocity and wall shear stress (WSS) at peak systole in patients with a bicuspid aortic valve (BAV) of which 52% had a repaired coarctation.
Methods
4D flow CMR was performed in 48 patients with BAV and in 25 healthy subjects at a spatiotemporal resolution of 2.5 × 2.5 × 2.5mm3/ ~ 42 ms and TE/TR/FA of 2.1 ms/3.4 ms/8° with k-t Principal Component Analysis factor R = 8. A 3D average of velocity and WSS direction was created for the normal subjects. Comparing BAV patient data with the 3D average map and selecting voxels deviating between 60° and 120° and > 120° yielded 3D maps and volume (in cm3) and surface (in cm2) quantification of abnormally directed velocity and WSS, respectively. Linear regression with Bonferroni corrected significance of P < 0.0125 was used to compare abnormally directed velocity volume and WSS surface in the ascending aorta with qualitative helicity and vorticity scores, with local normalized helicity (LNH) and quantitative vorticity and with patient characteristics.
Results
The velocity volumes > 120° correlated moderately with the vorticity scores (R ~ 0.50, P < 0.001 for both observers). For WSS surface these results were similar. The velocity volumes between 60° and 120° correlated moderately with LNH (R = 0.66) but the velocity volumes > 120° did not correlate with quantitative vorticity. For abnormal velocity and WSS deviating between 60° and 120°, moderate correlations were found with aortic diameters (R = 0.50-0.70). For abnormal velocity and WSS deviating > 120°, additional moderate correlations were found with age and with peak velocity (stenosis severity) and a weak correlation with gender. Ensemble maps showed that more than 60% of the patients had abnormally directed velocity and WSS. Additionally, abnormally directed velocity and WSS was higher in the proximal descending aorta in the patients with repaired coarctation than in the patients where coarctation was never present.
Conclusion
The possibility to reveal directional abnormalities of velocity and WSS in 3D provides a new tool for hemodynamic characterization in BAV disease.



J Cardiovasc Magn Reson: 14 Feb 2021; 23:9
van Ooij P, Farag ES, Blanken CPS, Nederveen AJ, ... Planken RN, Boekholdt SM
J Cardiovasc Magn Reson: 14 Feb 2021; 23:9 | PMID: 33588887
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Impact:
Abstract

Influence of aneurysmal aortic root geometry on mechanical stress to the aortic valve leaflet.

Hayashi H, Itatani K, Akiyama K, Zhao Y, ... Kainuma A, Takayama H
Aims
While mechanical stress caused by blood flow, e.g. wall shear stress (WSS), and related parameters, e.g. oscillatory shear index (OSI), are increasingly being recognized as key moderators of various cardiovascular diseases, studies on valves have been limited because of a lack of appropriate imaging modalities. We investigated the influence of aortic root geometry on WSS and OSI on the aortic valve (AV) leaflet.
Methods and results
We applied our novel approach of intraoperative epi-aortic echocardiogram to measure the haemodynamic parameters of WSS and OSI on the AV leaflet. Thirty-six patients were included, which included those who underwent valve-sparing aortic root replacement (VSARR) with no significant aortic regurgitation (n = 17) and coronary artery bypass graft (CABG) with normal AV (n = 19). At baseline, those who underwent VSARR had a higher systolic WSS (0.52 ± 0.12 vs. 0.32 ± 0.08 Pa, respectively, P < 0.001) and a higher OSI (0.37 ± 0.06 vs. 0.29 ± 0.04, respectively, P < 0.001) on the aortic side of the AV leaflet than those who underwent CABG. Multivariate regression analysis revealed that the size of the sinus of Valsalva had a significant association with WSS and OSI. Following VSARR, WSS and OSI values decreased significantly compared with the baseline values (WSS: 0.29 ± 0.12 Pa, P < 0.001; OSI: 0.26 ± 0.09, P < 0.001), and became comparable to the values in those who underwent CABG (WSS, P = 0.42; OSI, P = 0.15).
Conclusions
Mechanical stress on the AV gets altered in correlation with the size of the aortic root. An aneurysmal aortic root may expose the leaflet to abnormal fluid dynamics. The VSARR procedure appeared to reduce these abnormalities.

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

Eur Heart J Cardiovasc Imaging: 20 Feb 2021; epub ahead of print
Hayashi H, Itatani K, Akiyama K, Zhao Y, ... Kainuma A, Takayama H
Eur Heart J Cardiovasc Imaging: 20 Feb 2021; epub ahead of print | PMID: 33611382
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Impact:
Abstract

Comparison between conventional and compressed sensing cine cardiovascular magnetic resonance for feature tracking global circumferential strain assessment.

Kido T, Hirai K, Ogawa R, Tanabe Y, ... Mochizuki T, Kido T
Background
Feature tracking (FT) has become an established tool for cardiovascular magnetic resonance (CMR)-based strain analysis. Recently, the compressed sensing (CS) technique has been applied to cine CMR, which has drastically reduced its acquisition time. However, the effects of CS imaging on FT strain analysis need to be carefully studied. This study aimed to investigate the use of CS cine CMR for FT strain analysis compared to conventional cine CMR.
Methods
Sixty-five patients with different left ventricular (LV) pathologies underwent both retrospective conventional cine CMR and prospective CS cine CMR using a prototype sequence with the comparable temporal and spatial resolution at 3 T. Eight short-axis cine images covering the entire LV were obtained and used for LV volume assessment and FT strain analysis. Prospective CS cine CMR data over 1.5 heartbeats were acquired to capture the complete end-diastolic data between the first and second heartbeats. LV volume assessment and FT strain analysis were performed using a dedicated software (ci42; Circle Cardiovasacular Imaging, Calgary, Canada), and the global circumferential strain (GCS) and GCS rate were calculated from both cine CMR sequences.
Results
There were no significant differences in the GCS (- 17.1% [- 11.7, - 19.5] vs. - 16.1% [- 11.9, - 19.3; p = 0.508) and GCS rate (- 0.8 [- 0.6, - 1.0] vs. - 0.8 [- 0.7, - 1.0]; p = 0.587) obtained using conventional and CS cine CMR. The GCS obtained using both methods showed excellent agreement (y = 0.99x - 0.24; r = 0.95; p < 0.001). The Bland-Altman analysis revealed that the mean difference in the GCS between the conventional and CS cine CMR was 0.1% with limits of agreement between -2.8% and 3.0%. No significant differences were found in all LV volume assessment between both types of cine CMR.
Conclusion
CS cine CMR could be used for GCS assessment by CMR-FT as well as conventional cine CMR. This finding further enhances the clinical utility of high-speed CS cine CMR imaging.



J Cardiovasc Magn Reson: 21 Feb 2021; 23:10
Kido T, Hirai K, Ogawa R, Tanabe Y, ... Mochizuki T, Kido T
J Cardiovasc Magn Reson: 21 Feb 2021; 23:10 | PMID: 33618722
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Impact:
Abstract

Rapid ascending aorta stiffening in bicuspid aortic valve on serial cardiovascular magnetic resonance evaluation: comparison with connective tissue disorders.

Perez-Casares A, Dionne A, Gauvreau K, Prakash A
Background
Aortic stiffness has been shown to be abnormal in patients with bicuspid aortic valve (BAV), and is considered a component of the aortopathy associated with this condition. Progressive aortic stiffening associated with aging has been previously described in normal adults. However, it is not known if aging related aortic stiffening occurs at the same rate in BAV patients. We determined the longitudinal rate of decline in segmental distensibility in BAV patients using serial cardiovascular magnetic resonance (CMR) studies, and compared to previously published results from a group of patients with connective tissue disorders (CTD).
Methods
A retrospective review of CMR and clinical data on children and adults with BAV (n = 49, 73% male; 23 ± 11 years) with at least two CMRs (total 98 examinations) over a median follow-up of 4.1 years (range 1-9 years) was performed to measure aortic distensibility at the ascending (AAo) and descending aorta (DAo). Longitudinal changes in aortic stiffness were assessed using linear mixed-effects modeling. The comparison group of CTD patients had a similar age and gender profile (n = 50, 64% male; 20.6 ± 12 years).
Results
Compared to CTD patients, BAV patients had a more distensible AAo early in life but showed a steeper decline in distensibility on serial examinations [mean 10-year decline in AAo distensibility (× 10-3 mmHg-1) 2.4 in BAV vs 1.3 in CTD, p = 0.005]. In contrast, the DAo was more distensible in BAV patients throughout the age spectrum, and DAo distensibility declined with aging at a rate similar to CTD patients [mean 10 year decline in DAo distensibility (× 10-3 mmHg-1) 0.3 in BAV vs 0.4 in CTD, p = 0.58].
Conclusions
On serial CMR measurements, AAo distensibility declined at significantly steeper rate in BAV patients compared to a comparison group with CTDs, while DAo distensibility declined at similar rates in both groups. These findings offer new mechanistic insights into the differing pathogenesis of the aortopathy seen in BAV and CTD patients.



J Cardiovasc Magn Reson: 21 Feb 2021; 23:11
Perez-Casares A, Dionne A, Gauvreau K, Prakash A
J Cardiovasc Magn Reson: 21 Feb 2021; 23:11 | PMID: 33618720
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Impact:
Abstract

Right ventricular systolic function in severe tricuspid regurgitation: prognostic relevance of longitudinal strain.

Ancona F, Melillo F, Calvo F, Attalla El Halabieh N, ... Alfieri O, Agricola E
Aims 
The aim of this study is to analyse the prognostic implications of right ventricular (RV) dysfunction as detected by strain analysis in patients with severe tricuspid regurgitation (TR). The evaluation of RV systolic function in presence of severe TR is of paramount importance for operative risk stratification; however, it remains challenging, as conventional echocardiographic indexes usually lead to overestimation.
Methods and results
We enrolled 250 consecutive patients with severe TR referred to our centre. Baseline clinical and echocardiographic data and follow-up outcomes were collected. Patients were predominantly female, with multiple cardiovascular risk factors and comorbidities, history of heart failure, and atrial fibrillation. Most of them had presented with clinical signs of RV heart failure (RVHF) and advanced New York Heart Association class. The RV strain analysis [both RV free wall longitudinal strain (RVFWLS) and RV global longitudinal strain (RVGLS)] reclassified ∼42-56% of patients with normal RV systolic function according to conventional parameters in patients with impaired RV systolic function. RVFWLS ≤17% (absolute values, AUC: 0.66, P = 0.002) predicted the presence of RVHF [odds ratio (OR) 0.93, P = 0.01]. At follow-up, patients with RVFWLS >14% (absolute values, AUC: 0.70, P = 0.001, sensitivity 72%, specificity 54%) showed a better survival (P = 0.01).
Conclusion
Different ranges of RVFWLS have different implications in patients with severe TR, allowing to identify a preclinical and a clinical window, with correlations to RVHF and survival.

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

Eur Heart J Cardiovasc Imaging: 23 Feb 2021; epub ahead of print
Ancona F, Melillo F, Calvo F, Attalla El Halabieh N, ... Alfieri O, Agricola E
Eur Heart J Cardiovasc Imaging: 23 Feb 2021; epub ahead of print | PMID: 33623973
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Impact:
Abstract

Age- and sex-based normal values of layer-specific longitudinal and circumferential strain by speckle tracking echocardiography: the Copenhagen City Heart Study.

Skaarup KG, Lassen MCH, Johansen ND, Olsen FJ, ... Møgelvang R, Biering-Sørensen T
Aims
Technical advancements in 2D-speckle tracking echocardiography (2DSTE) have allowed for quantification of layer-specific global longitudinal strain (GLS) and circumferential strain (GCS) of the left ventricle (LV). The aim of this study was to establish age- and sex-based reference ranges of peak systolic layer-specific GLS and GCS and to assess normal values of regional strain.
Methods and results
We performed 2DSTE analysis of 1997 members of the general population from the fifth round of the Copenhagen City Heart Study, who were free of cardiovascular disease and risk factors. The mean age was 46 ± 16 years (range 21-97) and 62% were female. Mean values for peak systolic whole wall GLS (GLSWW.Sys), endomycardial (GLSEndo.Sys), and epimyocardial (GLSEpi.Sys) were 19.9 ± 2.1% (prediction interval [PI]: 15.8-24.0%), 23.5 ± 2.5% (PI: 18.6-28.4%), and 17.3 ± 1.9% (PI: 13.6-21.1%), respectively. Mean peak systolic whole wall GCS (GCSWW.Sys), was 21.6 ± 3.7% (PI: 14.3-28.9%), endomyocardial (GCSEndo.Sys) was 31.9 ± 4.7% (PI: 22.7-41.1%), and epimyocardial (GCSEpi.Sys) was 14.3 ± 3.8% (PI: 6.8-21.8%). A significant discrepancy in normal strain values between males and females was observed. Men had lower mean values and lower reference limits for all strain parameters. Furthermore, GLS and GCS changed differently with age in males and females. Finally, regional LS decreased from the apical to the basal LV region in both sexes, and regional CS varied significantly by LV segment.
Conclusion
In this study, we reported age- and sex-based reference ranges of layer-specific GLS and GCS. These reference ranges varied significantly with sex and age.

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

Eur Heart J Cardiovasc Imaging: 23 Feb 2021; epub ahead of print
Skaarup KG, Lassen MCH, Johansen ND, Olsen FJ, ... Møgelvang R, Biering-Sørensen T
Eur Heart J Cardiovasc Imaging: 23 Feb 2021; epub ahead of print | PMID: 33624014
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Impact:
Abstract

Relationship between coronary hyper-intensive plaques identified by cardiovascular magnetic resonance and clinical severity of acute coronary syndrome.

Liu W, Wu S, Wang Z, Du Y, ... Yu W, Xie Y
Background
Coronary hyper-intense plaque (CHIP) detected on T1-weighted cardiovascular magnetic resonance (CMR) has been shown to associate with vulnerable plaque features and worse outcomes in low- and intermediate-risk populations. However, the prevalence of CHIP and its clinical significance in the higher-risk acute coronary syndrome (ACS) population have not been systematically studied. This study aims to assess the relationship between CHIP and ACS clinical severity using intracoronary optical coherence tomography (OCT) as the reference.
Methods
A total of 62 patients with known or suspected coronary artery disease were prospectively enrolled including a clinically diagnosed ACS group (n = 50) and a control group with stable angina pectoris (n = 12). The ACS group consisted of consecutive patients including unstable angina pectoris (n = 27), non-ST-segment-elevation myocardial infarction (non-STEMI) (n = 8), and ST-segment-elevation myocardial infarction (STEMI) (n = 15), respectively. All patients underwent non-contrast coronary CMR to determine the plaque-to-myocardium signal intensity ratio (PMR).
Results
Among the four groups of patients, a progressive increase in the prevalence of CHIPs (stable angina, 8%; unstable angina, 26%; non-STEMI, 38%; STEMI, 67%; p = 0.009), and PMR values (stable angina, 1.1; unstable angina, 1.2; non-STEMI, 1.3; STEMI, 1.6; median values, P = 0.004) were observed. Thrombus (7/8, 88% vs. 4/22, 18%, p = 0.001) and plaque rupture (5/8, 63% vs. 2/22, 9%, p = 0.007) were significantly more prevalent in CHIPs than in plaques without hyper-intensity. Elevated PMR was associated with high-risk plaque features including plaque rupture, thrombus, and intimal vasculature. A positive correlation was observed between PMR and the number of high-risk plaque features identified by OCT (r = 0.44, p = 0.015).
Conclusions
The prevalence of CHIPs and PMR are positively associated with the disease severity and high-risk plaque morphology in ACS.



J Cardiovasc Magn Reson: 24 Feb 2021; 23:12
Liu W, Wu S, Wang Z, Du Y, ... Yu W, Xie Y
J Cardiovasc Magn Reson: 24 Feb 2021; 23:12 | PMID: 33627144
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Impact:
Abstract

Stent interventions for pulmonary artery stenosis improve bi-ventricular flow efficiency in a swine model.

Pewowaruk RJ, Barton GP, Johnson C, Ralphe JC, ... Lamers L, Roldán-Alzate A
Background
Branch pulmonary artery (PA) stenosis (PAS) commonly occurs in patients with congenital heart disease (CHD). Prior studies have documented technical success and clinical outcomes of PA stent interventions for PAS but the impact of PA stent interventions on ventricular function is unknown. The objective of this study was to utilize 4D flow cardiovascular magnetic resonance (CMR) to better understand the impact of PAS and PA stenting on ventricular contraction and ventricular flow in a swine model of unilateral branch PA stenosis.
Methods
18 swine (4 sham, 4 untreated left PAS, 10 PAS stent intervention) underwent right heart catheterization and CMR at 20 weeks age (55 kg). CMR included ventricular strain analysis and 4D flow CMR.
Results
4D flow CMR measured inefficient right ventricular (RV) and left ventricular (LV) flow patterns in the PAS group (RV non-dimensional (n.d.) vorticity: sham 82 ± 47, PAS 120 ± 47; LV n.d. vorticity: sham 57 ± 5, PAS 78 ± 15 p < 0.01) despite the PAS group having normal heart rate, ejection fraction and end-diastolic volume. The intervention group demonstrated increased ejection fraction that resulted in more efficient ventricular flow compared to untreated PAS (RV n.d. vorticity: 59 ± 12 p < 0.01; LV n.d. vorticity: 41 ± 7 p < 0.001).
Conclusion
These results describe previously unknown consequences of PAS on ventricular function in an animal model of unilateral PA stenosis and show that PA stent interventions improve ventricular flow efficiency. This study also highlights the sensitivity of 4D flow CMR biomarkers to detect earlier ventricular dysfunction assisting in identification of patients who may benefit from PAS interventions.



J Cardiovasc Magn Reson: 24 Feb 2021; 23:13
Pewowaruk RJ, Barton GP, Johnson C, Ralphe JC, ... Lamers L, Roldán-Alzate A
J Cardiovasc Magn Reson: 24 Feb 2021; 23:13 | PMID: 33627121
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Impact:
Abstract

Assessing proportionate and disproportionate functional mitral regurgitation with individualized thresholds.

Lopes PM, Albuquerque F, Freitas P, Gama F, ... Mendes M, Andrade MJ
Aims
The concept of proportionate/disproportionate functional mitral regurgitation (FMR) has been limited by the lack of a simple way to assess it and by the paucity of data showing its prognostic superiority. The aim of this study was to evaluate the prognostic value of an individualized method of assessing FMR proportionality.
Methods and results
We retrospectively identified 572 patients with at least mild FMR and reduced left ventricular ejection fraction (<50%) under medical therapy. To determine FMR proportionality status, we used an approach where a simple equation determined the individualized theoretical regurgitant volume (or effective regurgitant orifice area) threshold associated with haemodynamically significant FMR. Then, we compared the measured with the theoretical value to categorize the population into non-severe, proportionate, and disproportionate FMR. The primary endpoint was all-cause mortality. During a median follow-up of 3.8 years (interquartile range: 1.8-6.2), 254 patients died. The unadjusted mortality incidence per 100 persons-year rose as the degree of FMR disproportionality worsened. On multivariable analysis, disproportionate FMR remained independently associated with all-cause mortality [adjusted hazard ratio: 1.785; 95% confidence interval (CI): 1.249-2.550; P = 0.001]. The FMR proportionality concept showed greater discriminative power (C-statistic 0.639; 95% CI: 0.597-0.680) than the American (C-statistic 0.583; 95% CI: 0.546-0.621; P for comparison <0.001) and European guidelines (C-statistic 0.584; 95% CI: 0.547-0.620; P for comparison <0.001). When added to any of the before-mentioned guidelines, FMR proportionality also improved risk stratification by reclassifying patients into lower and higher risk subsets.
Conclusion
Disproportionate FMR is independently associated with all-cause mortality and improves the risk stratification of current guidelines.

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

Eur Heart J Cardiovasc Imaging: 25 Feb 2021; epub ahead of print
Lopes PM, Albuquerque F, Freitas P, Gama F, ... Mendes M, Andrade MJ
Eur Heart J Cardiovasc Imaging: 25 Feb 2021; epub ahead of print | PMID: 33637993
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Impact:
Abstract

Circulatory efficiency in patients with severe aortic valve stenosis before and after aortic valve replacement.

Nordmeyer S, Lee CB, Goubergrits L, Knosalla C, ... Kuehne T, Kelm M
Background
Circulatory efficiency reflects the ratio between total left ventricular work and the work required for maintaining cardiovascular circulation. The effect of severe aortic valve stenosis (AS) and aortic valve replacement (AVR) on left ventricular/circulatory mechanical power and efficiency is not yet fully understood. We aimed to quantify left ventricular (LV) efficiency in patients with severe AS before and after surgical AVR.
Methods
Circulatory efficiency was computed from cardiovascular magnetic resonance (CMR) imaging derived volumetric data, echocardiographic and clinical data in patients with severe AS (n = 41) before and 4 months after AVR and in age and sex-matched healthy subjects (n = 10).
Results
In patients with AS circulatory efficiency was significantly decreased compared to healthy subjects (9 ± 3% vs 12 ± 2%; p = 0.004). There were significant negative correlations between circulatory efficiency and LV myocardial mass (r = - 0.591, p < 0.001), myocardial fibrosis volume (r = - 0.427, p = 0.015), end systolic volume (r = - 0.609, p < 0.001) and NT-proBNP (r = - 0.444, p = 0.009) and significant positive correlation between circulatory efficiency and LV ejection fraction (r = 0.704, p < 0.001). After AVR, circulatory efficiency increased significantly in the total cohort (9 ± 3 vs 13 ± 5%; p < 0.001). However, in 10/41 (24%) patients, circulatory efficiency remained below 10% after AVR and, thus, did not restore to normal values. These patients also showed less reduction in myocardial fibrosis volume compared to patients with restored circulatory efficiency after AVR.
Conclusion
In our cohort, circulatory efficiency is reduced in patients with severe AS. In 76% of cases, AVR leads to normalization of circulatory efficiency. However, in 24% of patients, circulatory efficiency remained below normal values even after successful AVR. In these patients also less regression of myocardial fibrosis volume was seen.
Trial registration:
clinicaltrials.gov NCT03172338, June 1, 2017, retrospectively registered.



J Cardiovasc Magn Reson: 28 Feb 2021; 23:15
Nordmeyer S, Lee CB, Goubergrits L, Knosalla C, ... Kuehne T, Kelm M
J Cardiovasc Magn Reson: 28 Feb 2021; 23:15 | PMID: 33641670
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Impact:
Abstract

Lymphatic pathway evaluation in congenital heart disease using 3D whole-heart balanced steady state free precession and T2-weighted cardiovascular magnetic resonance.

Gooty VD, Veeram Reddy SR, Greer JS, Blair Z, ... Dillenbeck J, Hussain T
Background
Due to passive blood flow in palliated single ventricle, central venous pressure increases chronically, ultimately impeding lymphatic drainage. Early visualization and treatment of these malformations is essential to reduce morbidity and mortality. Cardiovascular magnetic resonance (CMR) T2-weighted lymphangiography (T2w) is used for lymphatic assessment, but its low signal-to-noise ratio may result in incomplete visualization of thoracic duct pathway. 3D-balanced steady state free precession (3D-bSSFP) is commonly used to assess congenital cardiac disease anatomy. Here, we aimed to improve diagnostic imaging of thoracic duct pathway using 3D-bSSFP.
Methods
Patients underwent CMR during single ventricle or central lymphatic system assessment using T2w and 3D-bSSFP. T2w parameters included 3D-turbo spin echo (TSE), TE/TR = 600/2500 ms, resolution = 1 × 1 × 1.8 mm, respiratory triggering with bellows. 3D-bSSFP parameters included electrocardiogram triggering and diaphragm navigator, 1.6 mm isotropic resolution, TE/TR = 1.8/3.6 ms. Thoracic duct was identified independently in T2w and 3D-bSSFP images, tracked completely from cisterna chyli to its drainage site, and classified based on severity of lymphatic abnormalities.
Results
Forty-eight patients underwent CMR, 46 of whom were included in the study. Forty-five had congenital heart disease with single ventricle physiology. Median age at CMR was 4.3 year (range 0.9-35.1 year, IQR 2.4 year), and median weight was 14.4 kg (range, 7.9-112.9 kg, IQR 5.2 kg). Single ventricle with right dominant ventricle was noted in 31 patients. Thirty-eight patients (84%) were status post bidirectional Glenn and 7 (16%) were status post Fontan anastomosis. Thoracic duct visualization was achieved in 45 patients by T2w and 3D-bSSFP. Complete tracking to drainage site was attained in 11 patients (24%) by T2w vs 25 (54%) by 3D-bSSFP and in 28 (61%) by both. Classification of lymphatics was performed in 31 patients.
Conclusion
Thoracic duct pathway can be visualized by 3D-bSSFP combined with T2w lymphangiography. Cardiac triggering and respiratory navigation likely help retain lymphatic signal in the retrocardiac area by 3D-bSSFP. Visualizing lymphatic system leaks is challenging on 3D-bSSFP images alone, but 3D-bSSFP offers good visualization of duct anatomy and landmark structures to help plan interventions. Together, these sequences can define abnormal lymphatic pathway following single ventricle palliative surgery, thus guiding lymphatic interventional procedures.



J Cardiovasc Magn Reson: 28 Feb 2021; 23:16
Gooty VD, Veeram Reddy SR, Greer JS, Blair Z, ... Dillenbeck J, Hussain T
J Cardiovasc Magn Reson: 28 Feb 2021; 23:16 | PMID: 33641664
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Impact:
Abstract

Multiparametric exercise stress cardiovascular magnetic resonance in the diagnosis of coronary artery disease: the EMPIRE trial.

Le TT, Ang BWY, Bryant JA, Chin CY, ... Chin CWL, Cook SA
Background
Stress cardiovascular magnetic resonance (CMR) offers assessment of ventricular function, myocardial perfusion and viability in a single examination to detect coronary artery disease (CAD). We developed an in-scanner exercise stress CMR (ExCMR) protocol using supine cycle ergometer and aimed to examine the diagnostic value of a multiparametric approach in patients with suspected CAD, compared with invasive fractional flow reserve (FFR) as the reference gold standard.
Methods
In this single-centre prospective study, patients who had symptoms of angina and at least one cardiovascular disease risk factor underwent both ExCMR and invasive angiography with FFR. Rest-based left ventricular function (ejection fraction, regional wall motion abnormalities), tissue characteristics and exercise stress-derived (perfusion defects, inducible regional wall motion abnormalities and peak exercise cardiac index percentile-rank) CMR parameters were evaluated in the study.
Results
In the 60 recruited patients with intermediate CAD risk, 50% had haemodynamically significant CAD based on FFR. Of all the CMR parameters assessed, the late gadolinium enhancement, stress-inducible regional wall motion abnormalities, perfusion defects and peak exercise cardiac index percentile-rank were independently associated with FFR-positive CAD. Indeed, this multiparametric approach offered the highest incremental diagnostic value compared to a clinical risk model (χ2 for the diagnosis of FFR-positive increased from 7.6 to 55.9; P < 0.001) and excellent performance [c-statistic area under the curve 0.97 (95% CI: 0.94-1.00)] in discriminating between FFR-normal and FFR-positive patients.
Conclusion
The study demonstrates the clinical potential of using in-scanner multiparametric ExCMR to accurately diagnose CAD.
Trial registration
ClinicalTrials.gov, NCT03217227, Registered 11 July 2017-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03217227?id=NCT03217227&draw=2&rank=1&load=cart.



J Cardiovasc Magn Reson: 03 Mar 2021; 23:17
Le TT, Ang BWY, Bryant JA, Chin CY, ... Chin CWL, Cook SA
J Cardiovasc Magn Reson: 03 Mar 2021; 23:17 | PMID: 33658056
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Impact:
Abstract

Effect of sarcomere and mitochondria-related mutations on myocardial fibrosis in patients with hypertrophic cardiomyopathy.

Chung H, Kim Y, Park CH, Kim JY, ... Lee KA, Choi EY
Background
Myocardial fibrosis is an important prognostic factor in hypertrophic cardiomyopathy (HCM). However, the contribution from a wide spectrum of genetic mutations has not been well defined. We sought to investigate effect of sarcomere and mitochondria-related mutations on myocardial fibrosis in HCM.
Methods
In 133 HCM patients, comprehensive genetic analysis was performed in 82 nuclear DNA (33 sarcomere-associated genes, 5 phenocopy genes, and 44 nuclear genes linked to mitochondrial cardiomyopathy) and 37 mitochondrial DNA. In all patients, cardiovascular magnetic resonance (CMR) was performed, including 16-segmental thickness, late gadolinium enhancement (LGE), native and post-T1, extracellular volume fraction (ECV), and T2, along with echo-Doppler evaluations.
Results
Patients with sarcomere mutation (SM, n = 41) had higher LGE involved segment, % LGE mass, ECV and lower post-T1 compared to patients without SM (n = 92, all p < 0.05). When classified into, non-mutation (n = 67), only mitochondria-related mutation (MM, n = 24), only-SM (n = 36) and both SM and MM (n = 5) groups, only-SM group had higher ECV and LGE than the non-mutation group (all p < 0.05). In non-LGE-involved segments, ECV was significantly higher in patients with SM. Within non-SM group, patients with any sarcomere variants of uncertain significance had higher echocardiographic Doppler E/e\' (p < 0.05) and tendency of higher LGE amount and ECV (p > 0.05). However, MM group did not have significantly higher ECV or LGE amount than non-mutation group.
Conclusions
SMs are significantly related to increase in myocardial fibrosis. Although, some HCM patients had pathogenic MMs, it was not associated with an increase in myocardial fibrosis.



J Cardiovasc Magn Reson: 03 Mar 2021; 23:18
Chung H, Kim Y, Park CH, Kim JY, ... Lee KA, Choi EY
J Cardiovasc Magn Reson: 03 Mar 2021; 23:18 | PMID: 33658040
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Impact:

This program is still in alpha version.