Topic: Imaging

Abstract

Effects of blood pressure and heart rate circadian rhythms on left atrial function.

Zhao Y, Liu Y, Sun Q, Han J, ... Cong T, Jiang Y
Objective
We examined the associations among the circadian rhythms of blood pressure (BP), heart rate (HR) and left atrial function in essential hypertensive patients.
Methods
The study included 237 essential hypertensive patients who completed 24-h ambulatory BP, HR monitoring and two-dimensional speckle tracking echocardiography (2DSTE). The strain and strain rate images were studied, and the following parameters were measured: left atrial reservoir strain and strain rate (LAS-S and LASR-S), left atrial conduit strain and strain rate (LAS-E and LASR-E), and left atrial booster strain and strain rate (LAS-A and LASR-A). The left atrial stiffness index (LASI) was identified as the ratio of E/e\' to LAS-S. All participants were divided into three groups according to the percentage of nocturnal BP dipping (dippers, nondippers and reverse dippers).
Results
The LASI was significantly higher in BP reverse dippers than in dippers and nondippers. LAS-S, LAS-E and LASR-E were significantly lower in BP reverse dippers than dippers and nondippers. Multivariate logistic regression analysis demonstrated that age, night-time mean SBP and the percentage of nocturnal HR decline were independently related to an increased LASI.
Conclusion
Impairment of the left atrial reservoir and conduit functions was correlated with abnormal BP and HR circadian rhythms in hypertension. Increased left atrial stiffness was associated with night-time SBP and the percentage of nocturnal HR decline.

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

J Hypertens: 31 Oct 2021; 39:2318-2324
Zhao Y, Liu Y, Sun Q, Han J, ... Cong T, Jiang Y
J Hypertens: 31 Oct 2021; 39:2318-2324 | PMID: 34620813
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Abstract

Supraventricular Tachycardia Causing Left Ventricular Dysfunction.

Zaffalon D, Pagura L, Cannatà A, Barbati G, ... Merlo M, Sinagra G
There is limited evidence on characterization and natural history of supraventricular tachycardia (SVT)-induced left ventricular (LV) dysfunction. The aim of this work was to characterize clinical features and long-term evolution of SVT-induced LV dysfunction. Patients consecutively admitted with sustained SVT and heart rate >100 bpm as the only known cause of a new onset LV systolic dysfunction (i.e., LV ejection fraction [EF] <50%) were analyzed. Patients were then revaluated periodically. Recovered LVEF (i.e., ≥50%) and a composite of death, heart transplant or first episode of major ventricular arrhythmias were evaluated as study end-points. We enrolled 83 patients. After SVT therapy, 56 (67%) showed a recovered LVEF at the last follow-up of median 54 (interquartile range 36 to 87) months. Seventeen (30%) of those patients had a temporary new drop in LVEF during follow-up associated to high-rate SVT relapse. At presentation, patients with recovered LVEF were younger (52 vs 67 years respectively, p <0.001) and had higher LVEF (34% vs 27% respectively, p = 0.005) compared to non-recovered LVEF patients. Finally, 4% of recovered LVEF patients vs 26% of nonrecovered LVEF patients experienced death/heart transplant/major ventricular arrhythmias during follow-up (p = 0.004). In conclusion, after almost 5 years of follow-up, two-thirds of patients with high-rate SVT causing a newly diagnosed LV systolic dysfunction recovered and maintained normal LV function after SVT control, with a subsequent benign outcome. Long term individual surveillance is required in those patients, as arrhythmic recurrences and new drops in LVEF are common in the long term.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Nov 2021; 159:72-78
Zaffalon D, Pagura L, Cannatà A, Barbati G, ... Merlo M, Sinagra G
Am J Cardiol: 14 Nov 2021; 159:72-78 | PMID: 34656315
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Abstract

Clinical and Hemodynamic Effects of Percutaneous Edge-to-Edge Mitral Valve Repair in Atrial Versus Ventricular Functional Mitral Regurgitation.

Claeys MJ, Debonnaire P, Bracke V, Bilotta G, ... Ferdinande B, Dubois C
The present study aims to assess the clinical and hemodynamic impact of percutaneous edge-to-edge mitral valve repair with MitraClip in patients with atrial functional mitral regurgitation (A-FMR) compared with ventricular functional mitral regurgitation (V-FMR). Mitral regurgitation (MR) grade, functional status (New York Heart Association class), and major adverse cardiac events (MACE; all-cause mortality or hospitalization for heart failure) were evaluated in 52 patients with A-FMR and in 307 patients with V-FMR. In 56 patients, hemodynamic assessment during exercise echocardiography was performed before and 6 months after intervention. MR reduction after MitraClip implantation was noninferior in A-FMR compared with V-FMR (MR grade ≤2 at 6 months in 94% vs 82%, respectively, p <0.001 for noninferiority) and was associated with improvement of functional status (New York Heart Association class ≤2 at 6 months in 90% vs 80%, respectively, p = 0.2). Hemodynamic assessment revealed that cardiac output at 6 months was higher in A-FMR at rest (5.1 ± 1.5 L/min vs 3.8 ± 1.5 L/min, p = 0.002) and during peak exercise (7.9 ± 2.4 L/min vs 6.1 ± 2.1 L/min, p = 0.02). In addition, the reduction in systolic pulmonary artery pressure at rest was more pronounced in A-FMR: Δ SPAP -13.1 ± 15.1 mm Hg versus -2.2 ± 13.3 mm Hg (p = 0.03). MACE rate at follow-up was significantly lower in A-FMR versus V-FMR, with an adjusted odds ratio of 0.46 (95% confidence interval 0.24 to 0.88), which was caused by a reduction in hospitalization for heart failure. In conclusion, percutaneous edge-to-edge mitral valve repair with MitraClip is at least as effective in A-FMR as in V-FMR in reducing MR. However, the hemodynamic improvement and reduction of MACE were significantly better in A-FMR.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Dec 2021; 161:70-75
Claeys MJ, Debonnaire P, Bracke V, Bilotta G, ... Ferdinande B, Dubois C
Am J Cardiol: 14 Dec 2021; 161:70-75 | PMID: 34794621
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Abstract

Normal Ranges of Global Left Ventricular Myocardial Work Indices in Adults: A Meta-Analysis.

Truong VT, Vo HQ, Ngo TNM, Mazur J, ... Nagueh SF, Chung ES
Background
Recent studies have demonstrated left ventricular myocardial work (MW) is incremental in diagnosis and prognostication when compared to left ventricular ejection fraction and myocardial strain. We performed a meta-analysis of normal ranges of non-invasive MW indices including global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) and to determine confounder that may contribute to variance in reported values.
Methods
Four databases including Pubmed, Scopus, Embase, and Cochrane Library were searched through January 2021 using the key terms \"myocardial work\", \"global constructive work\", \"global wasted work\", \"global work index\", \"global work efficiency\". Studies were included if the articles reported LV myocardial work using 2D transthoracic echocardiography in healthy normal subjects, either in control group or comprising of the entire study cohort. The weighted mean was estimated by using the random effect model with a 95% confidence interval. Heterogeneity across included studies was assessed using the I2 test. Funnel plot and Egger\'s regression test were used to assess potential publication bias
Results:
The search yielded 476 articles. After abstract and full-text screening, we included 13 datasets with 1665 patients for the meta-analysis. The reported normal mean values of GWI and GCW among the studies were 2010 mmHg% (95% CI, 1907 to 2113), and 2278 mmHg% (95% CI, 2186 to 2369) respectively. The mean GWW was 80 mmHg% (95% CI, 73 to 87), and the mean GWE was 96.0% (95% CI, 96% to 96%). Furthermore, gender significantly contributed to variations in normal values of GWI, GWW, and GWE. No evidence of significant publication bias was observed.
Conclusion
In this meta-analysis, we provide echocardiographic reference ranges for non-invasive indices of MW. These normal values could be served as a reference for clinical and research use.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 16 Nov 2021; epub ahead of print
Truong VT, Vo HQ, Ngo TNM, Mazur J, ... Nagueh SF, Chung ES
J Am Soc Echocardiogr: 16 Nov 2021; epub ahead of print | PMID: 34800670
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Abstract

Long-term outcome of left atrial appendage occlusion with multiple devices.

Radinovic A, Falasconi G, Marzi A, D\'Angelo G, ... Della Bella P, Mazzone P
Background
To evaluate long-term efficacy of left atrial appendage occlusion with multiple devices.
Methods
All consecutive patients who underwent left atrial appendage occlusion (LAAO) with a follow-up of at least 4 years, were included in this single center, retrospective registry. No specific exclusion criteria were applied. LAA occlusion was performed with the Watchman, Watchman FLX, Amplatzer Cardiac plug or Amplatzer Amulet occluder devices.
Results
A total of 224 consecutive patients underwent LAAO occlusion. Mean age was 72.5 ± 9.0 years. A history of stroke was present in 29%, TIA in 8.5% and a previous episode of bleeding in 64.7% of patients. In 63% there was a contraindication to oral anticoagulants. The average CHADS-VASc was 4.0 ± 1.6 and the average HAS-BLED was 3.4 ± 1.3. There was a reduction of strokes of 72.9%, thromboembolic events of 59.7% and major bleeding events of 70.9% compared to historic data. During follow-up, 48.3% of the ischemic and major bleeding events occurred within the first year. The annual mortality rate of 7.5 deaths/ 100 patients years. There were no significant differences in terms of outcome between the devices used and there were no late events associated with any device. The main antithrombotic regimen in the long term was with single antiplatelet therapy and the second one was no therapy.
Conclusion
LAAO is a safe and effective procedure, that reduces ischemic and bleeding events in the long-term, regardless of the type of device used, in AF patients at high risk of ischemic stroke and major bleeding, without the need of anticoagulation.

Copyright © 2021 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Nov 2021; 344:66-72
Radinovic A, Falasconi G, Marzi A, D'Angelo G, ... Della Bella P, Mazzone P
Int J Cardiol: 30 Nov 2021; 344:66-72 | PMID: 34599944
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Impact:
Abstract

Assessment of independent clinical predictors of early readmission after percutaneous endoluminal left atrial appendage closure with the Watchman device using National Readmission Database.

Rahman MU, Amritphale A, Kumar S, Trice C, Awan GM, Omar BA
Background
Percutaneous endoluminal left atrial appendage closure (pLAAC) procedure has been used to prevent strokes in patients who are not eligible for long-term prophylactic anticoagulation. Since its approval, multiple studies have looked at its efficacy with comparable outcomes to anticoagulation, the current standard of care.
Objectives
To assess the readmission rate and determine the factors associated with readmission after the endocardial pLAAC procedure using the Watchman device.
Methods
Data was obtained from the National Readmission Database (NRD), and we used SPSS software to determine statistically significant clinical predictors affecting readmission after implantation of the Watchman device at 30 days.
Results
The rate of readmission was found to be 9.2%. The true median cost of index hospitalization for the total population in the study was found to be [median (interquartile range = IQR), p] USD 24594 (USD 18883-31,041), whereas the true median cost of admission for those who were getting readmitted after 30 days was [median (IQR)] USD 7699 (USD 4955-14,243). Multivariate analysis of all clinically relevant predictors showed adjusted ratio for [adjusted odds ratio (OR), 95% confidence interval (95% CI), p-value] female genders (1.288, 1.104-1.503, p = 0.001), discharge to home health care (6.155, 1.509-25.096, p = 0.01), chronic kidney disease (CKD) (1.847,1.511-2.258, p < 0.001), chronic lung disease (1.419, 1.194-1.686, p < 0.001), heart failure (1.280, 1.040-1.574, p = 0.02), pericardial disorders (1.485, 1.011-2.179, p = 0.04), fluid and electrolyte disorders (1.456,1.050-2.018, p = 0.02) in those who were getting readmitted at 30-days compared to those who were not readmitted. The median length of stay for the index hospitalization was found to be one day, whereas the median length of stay at the 30-day readmission was reported to be [Median (IQR)] 4 days (2-6 days). Major cardiac reasons for readmission were heart failure, arrhythmias, and pericardial disorders.
Conclusion
Our study aims to assess 30-day outcomes in the US population after pLAAC using a Watchman device. Our analysis showed that one in ten patients were getting readmitted. In addition, chronic kidney disease, chronic obstructive pulmonary disease, heart failure, and pericardial disorders were associated with higher readmission rates. These findings will help us assess clinical correlations and predict which patients are more at risk of readmission after a Watchman procedure.

Copyright © 2021 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Nov 2021; 343:21-26
Rahman MU, Amritphale A, Kumar S, Trice C, Awan GM, Omar BA
Int J Cardiol: 14 Nov 2021; 343:21-26 | PMID: 34481838
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Abstract

Left Atrial Stiffness Index Independently Predicts Exercise Intolerance and Quality of Life in Older Patients with Obese HFpEF.

Singleton MJ, Nelson MB, Samuel TJ, Kitzman DW, ... Chen H, Nelson MD
Background
Heart failure with preserved ejection fraction (HFpEF) is the fastest growing form of HF and is associated with high morbidity and mortality. The primary chronic symptom in HFpEF is exercise intolerance, associated with reduced quality of life (QoL). Emerging evidence implicates left atrial (LA) dysfunction as an important pathophysiologic mechanism. Here we extend prior observations by relating LA dysfunction to peak oxygen uptake (peak VO2), physical function (distance walked in six minutes, 6MWD) and QoL (Kansas City Cardiomyopathy Questionnaire, KCCQ).
Methods
We compared 75 older, obese, HFpEF patients to 53 healthy age-matched controls. LA strain was assessed by magnetic resonance cine imaging using feature tracking. LA function was defined according to its three distinct phases, with the LA serving as a reservoir during systole, as a conduit during early diastole, and as a booster pump at the end of diastole. LA stiffness index was calculated as the ratio of early mitral inflow velocity-to-early annular tissue velocity (E/e\', by Doppler ultrasound) and LA reservoir strain.
Results
HFpEF had decreased reservoir strain (16.4±4.4% vs. 18.2±3.5%, p=0.018), lower conduit strain (7.7±3.3% vs. 9.1±3.4%, p=0.028), and increased stiffness index (0.86±0.39 vs. 0.53±0.18, p<0.001), as well as decreased peak VO2, 6MWD, and lower QoL. Increased LA stiffness was independently associated with impaired peak VO2 (β=9.0±1.6, p<0.001), 6MWD (β=117±22, p=0.003), and KCCQ score (β=-23±5, p=0.001), even after adjusting for clinical covariates.
Conclusion
LA stiffness is independently associated with impaired exercise tolerance and QoL and may be an important therapeutic target in obese HFpEF.
Registration
NCT00959660.

Copyright © 2021 Elsevier Ltd. All rights reserved.

J Card Fail: 09 Nov 2021; epub ahead of print
Singleton MJ, Nelson MB, Samuel TJ, Kitzman DW, ... Chen H, Nelson MD
J Card Fail: 09 Nov 2021; epub ahead of print | PMID: 34774747
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Abstract

Cardiac microvascular functions improved by MSC-derived exosomes attenuate cardiac fibrosis after ischemia-reperfusion via PDGFR-β modulation.

Wang X, Bai L, Liu X, Shen W, ... Liu W, Yu B
Microvascular dysfunction caused by cardiac ischemia-reperfusion (I/R) leads to multiple severe cardiac adverse events, such as heart failure and ventricular modeling, which plays a critical role in outcomes. Though marrow mesenchymal stem cell (MSC) therapy has been proven effective for attenuating I/R injury, the limitations of clinical feasibility cannot be ignored. Since exosomes are recognized as the main vehicles for MSCs paracrine effects, we assumed that MSC-derived exosomes could prevent microvascular dysfunction and further protect cardiac function. By establishing a rat cardiac I/R model in vivo and a cardiac microvascular endothelial cells (CMECs) hypoxia-reperfusion (H/R) model in vitro, we demonstrated that MSC-derived exosomes enhanced microvascular regeneration under stress, inhibited fibrosis development, and eventually improved cardiac function through platelet-derived growth factor receptor-β (PDGFR-β) modulation. Furthermore, we found that MSC-derived exosomes possessed better therapeutic effects than MSCs themselves.

Copyright © 2021 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Nov 2021; 344:13-24
Wang X, Bai L, Liu X, Shen W, ... Liu W, Yu B
Int J Cardiol: 30 Nov 2021; 344:13-24 | PMID: 34534604
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Abstract

Ventricular Changes in Patients with Acute COVID-19 Infection: Follow-Up of The World Alliance Societies of Echocardiography (WASE-COVID) Study.

Karagodin I, Carvalho Singulane C, Descamps T, Woodward GM, ... Asch FM, WASE-COVID Investigators
Background
COVID-19 infection is known to cause a wide array of clinical chronic sequelae but little is known regarding the long-term cardiac complications. We aim to report echocardiographic follow-up findings and describe the changes in left and right ventricular function that occur following acute infection.
Methods
Patients enrolled in the WASE-COVID study with acute COVID-19 infection were asked to return for a follow-up transthoracic echocardiogram (TTE). Overall, 198 returned at a mean of 129 days of follow-up, of which 153 had paired baseline and follow-up images that were analyzable, including left ventricular (LV) volumes, ejection fraction (EF), and longitudinal strain (LVLS). Right-sided echocardiographic parameters included right ventricular (RV) global longitudinal strain (RVGLS), RV free wall strain (RVFWS), and RV basal diameter (RVBD). Paired echocardiographic parameters at baseline and follow-up were compared for the entire cohort and for subgroups based on the baseline LV and RV function.
Results
For the entire cohort, echocardiographic markers of LV and RV function at follow-up were not significantly different from baseline (all p>0.5). Patients with hyperdynamic LVEF at baseline (>70%), had a significant reduction of LVEF at follow-up (74.3±3.1% vs. 64.4±8.1 %, p<0.001), while patients with reduced LVEF at baseline (<50%) had a significant increase (42.5±5.9% vs 49.3±13.4% , p=0.02), and those with normal LVEF had no change. Patients with normal LVLS (<-18%) at baseline, had a significant reduction of LVLS at follow-up (-21.6±2.6 % vs. -20.3±4.0% , p=0.006), while patients with impaired LVLS at baseline, had a significant improvement at follow-up (-14.5±2.9 % vs. -16.7±5.2%, p<0.001). Patients with abnormal RVGLS (>-20%) at baseline, had significant improvement at follow-up (-15.2±3.4 % vs. -17.4±4.9 %, p=0.004). Patients with abnormal RVBD (>4.5 cm) at baseline, had significant improvement at follow-up (4.9±0.7 cm vs 4.6±0.6 cm, p=0.019).
Conclusions
Overall, there were no significant changes overtime in LV and RV function of patients recovering from COVID-19 infection. However, differences were observed according to baseline LV and RV function, which may reflect recovery from the acute myocardial injury occurring in the acutely ill. LV and RV function tends to improve in those with impaired baseline function, while it tends to decrease in those with hyperdynamic LV or normal RV.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Nov 2021; epub ahead of print
Karagodin I, Carvalho Singulane C, Descamps T, Woodward GM, ... Asch FM, WASE-COVID Investigators
J Am Soc Echocardiogr: 05 Nov 2021; epub ahead of print | PMID: 34752928
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Abstract

Resting Left Ventricular Global Longitudinal Strain to Identify Silent Myocardial Ischemia in Asymptomatic Patients with Diabetes Mellitus.

Albenque G, Rusinaru D, Bellaiche M, Di Lena C, ... Tribouilloy C, Bohbot Y
Background
Screening silent coronary artery disease (CAD) in asymptomatic patients with diabetes mellitus (DM) is challenging and controversial. In this context, it seems crucial to identify early markers of CAD.
Methods
We aimed to investigate the incremental value of resting left ventricular global longitudinal strain (LV GLS) for the prediction of positive stress (exercise or Dobutamine) TTE in 273 consecutive asymptomatic high-risk patients with diabetes mellitus (DM). Positive stress TTE was defined as stress-induced left ventricular wall motion abnormalities (new or worsening of pre-existing abnormalities).
Results
Compared to patients with negative stress test, patients with positive stress test (n=28, 10%) had more frequent cardiovascular risk factors, complications of diabetes, vascular disease, moderate and severe calcification of the aortic valve and mitral annulus and worse resting LV GLS (-16.7±2.9 vs. -19.0±1.9%; p<0.001). On multivariable logistic regression analysis, DM duration >10 years, diabetic retinopathy, left ventricular hypertrophy and impaired LV GLS (OR[95%CI]=1.39 [1.14-1.70] per % increase, OR[95%CI]=5.16[1.96-13.59] for LV GLS worse than -18%) were independently associated with a positive stress TTE. The AUC to predict the test positivity was 0.74 for LV GLS with a cutoff of -18.0% (se=68%, spe=78%). The AUC of the multivariable model to predict test results was improved by the addition of LV GLS (p<0.001) with a bias-corrected AUC after bootstraping of 0.842 [95%CI:0.753-0.893].
Conclusion
Our study supports that resting LV GLS is associated with the presence of silent ischemia and could be useful to better identify asymptomatic patients with DM who might benefit from CAD screening.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Nov 2021; epub ahead of print
Albenque G, Rusinaru D, Bellaiche M, Di Lena C, ... Tribouilloy C, Bohbot Y
J Am Soc Echocardiogr: 05 Nov 2021; epub ahead of print | PMID: 34752929
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Abstract

Myocardial contraction fraction by echocardiography and mortality in cardiac intensive care unit patients.

Jentzer JC, Wiley BM, Gersh BJ, Borlaug BA, Oh JK, Anavekar NS
Background
The myocardial contraction fraction (MCF) is proposed as an improved measure of left ventricular (LV) systolic function that overcomes important limitations of the left ventricular ejection fraction (LVEF). We sought to determine whether a low MCF was associated with higher mortality in cardiac intensive care unit (CICU) patients.
Methods
We retrospectively analyzed unique Mayo Clinic CICU patients from 2007 to 2018 with MCF calculated as the ratio of the stroke volume to the left ventricular myocardial volume from a transthoracic echocardiogram within 1 day of CICU admission. Multivariable logistic regression analyzed the association between MCF and hospital mortality, after adjustment for LVEF and clinical variables.
Results
We included 4794 patients with a mean age of 68.0 ± 14.8 years (37.1% females). The mean MCF was 0.41 ± 0.16, and was lower in the 6.6% of patients who died in the hospital (0.32 ± 0.14 versus 0.42 ± 0.16, p < 0.001). On multivariable analysis, higher MCF remained associated with lower hospital mortality (adjusted OR 0.78 per 0.1 higher, 95% CI 0.69-0.89, p < 0.001), whereas LVEF was not significantly associated with hospital mortality (unadjusted OR 0.91 per 10% higher, OR 95% CI 0.82-1.02, p = 0.09). Patients with MCF <0.2 had the highest in-hospital mortality, and those with MCF ≥0.5 had the lowest in-hospital mortality, irrespective of admission diagnosis or LVEF.
Conclusions
MCF demonstrated a strong, inverse relationship with hospital mortality in CICU patients, even after adjusting for LVEF and clinical variables. MCF can be used to identify prognostically-relevant myocardial dysfunction at the bedside, even among patients with preserved LVEF.

Copyright © 2021 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Nov 2021; 344:230-239
Jentzer JC, Wiley BM, Gersh BJ, Borlaug BA, Oh JK, Anavekar NS
Int J Cardiol: 30 Nov 2021; 344:230-239 | PMID: 34563594
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Abstract

Cardiovascular magnetic resonance characterisation of anthracycline cardiotoxicity in adults with normal left ventricular ejection fraction.

Harries I, Berlot B, Ffrench-Constant N, Williams M, ... Plana JC, Bucciarelli-Ducci C
Background
Anthracycline therapy may lead to changes in cardiac structure and function not detectable by solely evaluating left ventricular ejection fraction (LVEF).
Objectives
We hypothesized that cardiovascular magnetic resonance (CMR) would identify structural and functional myocardial abnormalities in anthracycline-treated cancer survivors with normal LVEF, compared to a matched control population.
Methods
Forty-five cancer survivors (56 ± 16 yrs., 60% female) with normal LVEF (59.5 ± 4.1%) were studied a median of 11 months (range 3-36) following administration of 237 ± 83 mg/m2 anthracycline, and compared with forty-five healthy control subjects of similar age and sex (53 ± 16 yrs., 60% female) with normal LVEF (60.8 ± 2.4%) using 1.5 T CMR.
Results
Significantly smaller indexed left ventricular mass (45.6 ± 8.7 vs 50.3 ± 10.1 g/m2, p = 0.02) and indexed myocardial cell volume (30.5 ± 5.7 vs 34.8 ± 7.2 ml/m2, p = 0.002) were evident in cancer survivors and the latter was inversely associated with cumulative anthracycline dose (r = -0.31, p = 0.02). Surrogate CMR markers of myocardial fibrosis were significantly increased in cancer survivors (native myocardial T1: 1021 ± 40 vs 996 ± 35 ms, p = 0.002; extracellular volume: 29.5 ± 4.5 vs 27.4 ± 2.3%, p = 0.006). CMR-derived feature-tracking global longitudinal strain (GLS) was significantly impaired in cancer survivors (2D GLS -18.3 ± 2.6 vs -20.0 ± 2.0%, p < 0.001; 3D GLS -14.5 ± 2.3 vs -16.4 ± 2.6%, p < 0.001). Parameters exhibited good to excellent (ICC = 0.86-0.98) inter- and intra-observer reproducibility.
Conclusions
Anthracycline-treated cancer survivors with normal LVEF have significant perturbations of LV mass, myocardial cell volume, native myocardial T1, ECV, CMR-derived 2D and 3D GLS, compared to controls, with good to excellent levels of inter- and intra-observer reproducibility.

Copyright © 2021 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Nov 2021; 343:180-186
Harries I, Berlot B, Ffrench-Constant N, Williams M, ... Plana JC, Bucciarelli-Ducci C
Int J Cardiol: 14 Nov 2021; 343:180-186 | PMID: 34454967
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Impact:
Abstract

Association of 3D Mesh-Derived Right Ventricular Strain with Short-Term Outcome in Patients Undergoing Cardiac Surgery.

Keller M, Heller T, Duerr MM, Schlensak C, ... Rosenberger P, Magunia H
Background
3D right ventricular (RV) strain analysis is not routinely performed perioperatively. While 3D RV strain adds incrementally to outcome prediction in various cardiac diseases, its role in the perioperative setting is not sufficiently understood. This study investigated the association between 3D RV strain measured on RV meshes created from 3D transesophageal echocardiography (TEE) data and short-term outcomes of patients undergoing cardiac surgery.
Methods
A total of 496 patients undergoing cardiac surgery who underwent intraoperative 3D TEE (under general anesthesia, before sternotomy) were retrospectively selected and RV meshes were generated using commercially available speckle-tracking software. Custom-made software automatically quantified longitudinal and circumferential RV strains on the mesh surfaces. Echocardiographic and clinical parameters were entered into logistic regression models to determine their association with the primary (in-hospital death or need for extracorporeal life support) and secondary endpoints (postoperative ventilation >48 hours).
Results
Mesh-derived RV strain analysis was feasible in 94% of patients and revealed distinct regional patterns with basal-apical gradients for both longitudinal and circumferential strain. Thirty-seven patients (7.6%) reached the primary endpoint, and 118 patients (23.8%) reached the secondary endpoint. In a multivariable logistic regression model, serum lactate (p<0.01), an emergency indication for surgery (p<0.01), tricuspid regurgitation (p<0.001) and mesh-derived RV global longitudinal strain (RV-GLS, p<0.01) were independently associated with the primary endpoint, while established measures of RV function (3D RV ejection fraction, fractional area change, tricuspid annular plane systolic excursion) and left ventricular (LV) function (3D-derived LV ejection fraction and LV-GLS) were not independently associated. Hematocrit (p<0.01), serum lactate (p<0.001), pulmonary hypertension (p=0.04), tricuspid regurgitation (p<0.01), emergency procedures (p=0.02), LV-GLS (p=0.02) and RV-GLS (p<0.001) were associated with the secondary endpoint.
Conclusions
RV-GLS measured on RV meshes derived from 3D TEE was independently associated with short-term outcomes in patients undergoing cardiac surgery and might be helpful for identifying patients at risk for adverse postoperative events.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 14 Nov 2021; epub ahead of print
Keller M, Heller T, Duerr MM, Schlensak C, ... Rosenberger P, Magunia H
J Am Soc Echocardiogr: 14 Nov 2021; epub ahead of print | PMID: 34793944
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Impact:
Abstract

Comparison between non-dedicated and novel dedicated tracking tool for right ventricular and left atrial strain.

Mirea O, Duchenne J, Voigt JU
Background
Recently, dedicated speckle tracking solutions for right ventricular (RV) and left atrial (LA) strain assessment have become commercially available.
Aims
To assess the level of agreement between non-dedicated (left ventricular (LV) tracking software) and novel dedicated tracking software for right ventricular and left atrial strain.
Methods
In 200 patients with various cardiovascular pathologies, we measured global longitudinal strain (GLS), free wall strain (FWS) and segmental values, as well as LA strain during reservoir (LASr), conduit (LAScd) and contraction (LASct) phase by using the 1) LV tracking software, and 2) the novel dedicated tracking software for RV or LA strain analysis. Agreement between corresponding measurements obtained with the LV and dedicated RV or LA software was determined by using mean absolute difference (MAD) and Bland-Altman test. The intra and inter-observer reproducibility related to the non-dedicated and novel dedicated tracking software was tested in 30 randomly selected subjects.
Results
The dedicated RV tracking software provided slightly lower strain values without reaching statistical significance. The agreement between software was best for RV-GLS (MAD: 2.4±1.8) and significantly poorer for segmental values (MAD ranging from 4.5±3.8 to 5.1±4.0, ANOVA, p<0.05). The intra- and inter-observer reproducibility for RV measurements was similar with both software (p>0.05 for all parameters). LA mean values showed no statistical difference when obtained with the two tracking tools. The use of LA dedicated tracking software increased significantly the intra- and inter-observer reproducibility for LASr and LASct (p<0.01 for both).
Conclusions
Our results suggest that the choice of tracking software does not significantly impact RV strain measurements. Nonetheless, the use of the same tracking software is recommended when performing serial measurements. The use of the dedicated software for LA strain analysis improved significantly the intra- and inter-observer reproducibility.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 16 Nov 2021; epub ahead of print
Mirea O, Duchenne J, Voigt JU
J Am Soc Echocardiogr: 16 Nov 2021; epub ahead of print | PMID: 34800672
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Impact:
Abstract

Prognostic relevance of peri-infarct zone measured by cardiovascular magnetic resonance in patients with ST-segment elevation myocardial infarction.

Jensch PJ, Stiermaier T, Reinstadler SJ, Feistritzer HJ, ... Thiele H, Eitel I
Background
Cardiac magnetic resonance (CMR) imaging provides valuable prognostic information in patients with ST-elevation myocardial infarction (STEMI). The peri-infarct zone (PIZ) is a potential marker for post-infarction risk stratification. The aim of this study was to assess the prognostic impact of PIZ in a large multicenter STEMI-trial.
Methods
The study population consisted of 704 consecutive patients undergoing CMR within 10 days after STEMI to assess established parameters of myocardial injury and additionally the extent of PIZ. The primary clinical endpoint was major adverse cardiac events (MACE) consisting of death, re-infarction and new congestive heart failure within 1 year after infarction.
Results
The median heterogeneous PIZ-volume in the overall population was 14 ml (interquartile range [IQR] 7 to 24 ml). Male sex, infarct size, and left ventricular ejection fraction were identified as independent predictors of larger PIZ alterations. Patients with MACE had a significantly larger PIZ volume compared to patients without adverse events (21 ml [IQR 12 to 35 ml] versus 14 ml [IQR 7 to 23 ml]; p = 0.001). In stepwise multivariable Cox regression analysis, PIZ > median (>14 ml) emerged as an independent predictor of MACE (hazard ratio [HR] 2.84; 95% confidence interval [CI] 1.34 to 6.00; p = 0.006) in addition to the Thrombolysis In Myocardial Infarction (TIMI) risk score (HR 1.53; 95% CI 1.19 to 1.53; p < 0.001). Addition of PIZ to a CMR risk model comprising LVEF, infarct size and microvascular obstruction resulted in net reclassification improvement of 0.46 (0.19-0.73, p < 0.001).
Conclusion
In this currently largest prospective, multicenter CMR study assessing PIZ, the extent of PIZ emerged as an independent predictor of MACE and a potential novel marker for optimized risk stratification in STEMI patients. ClinicalTrials.gov: NCT00712101.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 08 Nov 2021; epub ahead of print
Jensch PJ, Stiermaier T, Reinstadler SJ, Feistritzer HJ, ... Thiele H, Eitel I
Int J Cardiol: 08 Nov 2021; epub ahead of print | PMID: 34767896
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Impact:
Abstract

Transcatheter edge-to-edge mitral valve repair in atrial functional mitral regurgitation insights from the multi-center MITRA-TUNE registry.

Rubbio AP, Testa L, Grasso C, Sisinni A, ... Tamburino C, Bedogni F
Background
A-FMR is considered a specific sub-type of secondary MR in patients with atrial fibrillation (AF) and preserved left ventricle ejection fraction (LVEF). Aim of the study was to investigate the acute and mid-term outcomes of transcatheter edge-to-edge mitral valve repair (TMVr) with the MitraClip in atrial functional mitral regurgitation (A-FMR).
Methods
The study included patients with A-FMR and concomitant AF who underwent to the MitraClip at 7 Italian Centers. Aim of the study was to assess the safety, efficacy and mid-term cardiovascular outcomes.
Results
After reviewing 1153 patients with FMR treated with TMVr from 2009 to 2021, 87 patients (median age 81 years, 61% female) with A-FMR were identified. Technical success was achieved in 97%, 30-day device success in 83% and 30-day procedural success in 80%. All-cause death at 30-day was 5%. Estimated two-year freedom from all-cause death and cardiac death was 60% and 77%, respectively, whereas freedom from all-cause death/heart failure hospitalization was 55%. Residual MR ≤ 2+ was encountered in 89% (n = 47/53) and improvement in NYHA class I/II in 79% (n = 48/61). Post-procedural MR ≥ 2+ (HR 5.400, CI 1.371-21.268) and inter-commissural annular diameter ≥ 35 mm (HR 4.159, CI 1.057-16.363) were independent predictors of all-cause death/heart failure hospitalization during the follow-up. Positive reverse remodeling of left atrium and mitral annular dimensions occurred after TMVr during the follow-up.
Conclusions
MitraClip resulted to be a safe and effective option to treat A-FMR in elderly patients.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 22 Nov 2021; epub ahead of print
Rubbio AP, Testa L, Grasso C, Sisinni A, ... Tamburino C, Bedogni F
Int J Cardiol: 22 Nov 2021; epub ahead of print | PMID: 34826500
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Impact:
Abstract

Loss of left ventricular rotation is a significant determinant of functional mitral regurgitation.

Hasin T, Mann D, Welt M, Barrett O, ... Glikson M, Wolak A
Aim
To evaluate insufficient rotational movement of the left ventricle (LV) as a potential novel mechanism for functional regurgitation of the mitral valve (FMR).
Methods and results
We compared reference subjects and patients with LV dysfunction (LVD, ejection fraction EF < 50%) with and without FMR (regurgitant volume RVol>10 ml). Subjects without structural mitral valve pathology undergoing cardiac MRI were evaluated. Delayed enhancement, global LV remodeling parameters, systolic twist and torsion were measured (using manual and novel automated cardiac MRI tissue-tracking). The study included 117 subjects with mean ± SD age 50.4 ± 17.8 years, of which 30.8% were female. Compared to subjects with LVD without FMR (n = 31), those with FMR (n = 37) had similar clinical characteristics, diagnoses, delayed enhancement, EF, and longitudinal strain. Subjects with FMR had significantly larger left ventricles (EDVi:136.6 ± 41.8 vs 97.5 ± 26.2 ml/m, p < 0.0001) with wider separation between papillary muscles (21.1 ± 7.6 vs 17.2 ± 5.7 mm, p = 0.023). Notably, they had lower apical (p < 0.0001) but not basal rotation and lower peak systolic twist (3.1 ± 2.4° vs 5.5 ± 2.5°, p < 0.0001) and torsion (0.56 ± 0.38°/cm vs 0.88 ± 0.52°/cm, p = 0.004). In a multivariate model for RVol including age, gender, twist, LV end-diastolic volume, sphericity index and separation between papillary muscles, only gender, volume and twist were significant. Twist was the most powerful correlate (beta -2.23, CI -3.26 to -1.23 p < 0.001). In patients with FMR, peak systolic twist negatively correlates with RVol (r = -0.73, p < 0.0001).
Conclusion
Reduced rotational systolic LV motion is significantly and independently associated with RVol among patients with FMR, suggesting a novel pathophysiological mechanism and a potential therapeutic target.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 14 Dec 2021; 345:143-149
Hasin T, Mann D, Welt M, Barrett O, ... Glikson M, Wolak A
Int J Cardiol: 14 Dec 2021; 345:143-149 | PMID: 34626742
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Impact:
Abstract

Clinical and echocardiographic outcomes of transcatheter mitral valve repair in atrial functional mitral regurgitation.

Benito-González T, Carrasco-Chinchilla F, Estévez-Loureiro R, Pascual I, ... Alonso-Briales JH, Fernández-Vázquez F
Background
Isolated atrial fibrillation can cause mitral regurgitation (MR) in patients with normal left ventricular systolic function and no organic disease of the mitral valve. Little information is available regarding outcomes of Mitraclip in patients with atrial functional mitral regurgitation (AFMR). We aimed to evaluate 12-month clinical and echocardiographic outcomes of transcatheter mitral valve repair (TMVR) with MitraClip in patients with AFMR compared to those with ventricular functional or degenerative/mixed MR.
Methods
Registry-based analysis of all consecutive patients who underwent TMVR and were included in the Spanish Registry of Mitraclip. Changes in MR and NYHA functional class, and a combined endpoint including all-cause mortality and hospitalizations due to heart failure were the main outcomes.
Results
Overall, 1074 (69.1% male, 73.3 ± 10.2 years-old) patients were analyzed in this report. 48 patients (4.5%) presented AFMR. AFMR was significantly reduced after TMVR, with a procedural success rate of 91.7%, and this reduction persisted at 12-month (p < 0.001). Patients with AFMR showed a significant functional improvement at 6- and 12-month follow-up in our series (baseline: NYHA III 70.8% IV 18.8% vs. 1-year: NYHA III 21.7% IV 0%; p < 0.001). The probability of survival free of readmission for heart failure and all-cause mortality within the first year after TMVR was 74.9%. Procedural and clinical outcomes, as well as recurrent rates of MR were similar acutely and at 1-year compared to other etiologies.
Conclusion
TMVR in patients with AFMR showed no significant differences compared to ventricular functional or degenerative/mixed MR regarding MR reduction or clinical outcomes.

Copyright © 2021 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Dec 2021; 345:29-35
Benito-González T, Carrasco-Chinchilla F, Estévez-Loureiro R, Pascual I, ... Alonso-Briales JH, Fernández-Vázquez F
Int J Cardiol: 14 Dec 2021; 345:29-35 | PMID: 34610357
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Impact:
Abstract

Understanding the Aortic Root Using Computed Tomographic Assessment: A Potential Pathway to Improved Customized Surgical Repair.

Tretter JT, Izawa Y, Spicer DE, Okada K, ... Quintessenza JA, Mori S
There is continued interest in surgical repair of both the congenitally malformed aortic valve, and the valve with acquired dysfunction. Aortic valvar repair based on a geometric approach has demonstrated improved durability and outcomes. Such an approach requires a thorough comprehension of the complex 3-dimensional anatomy of both the normal and congenitally malformed aortic root. In this review, we provide an understanding of this anatomy based on the features that can accurately be revealed by contrast-enhanced computed tomographic imaging. We highlight the complimentary role that such imaging, with multiplanar reformatting and 3-dimensional reconstructions, can play in selection of patients, and subsequent presurgical planning for valvar repair. The technique compliments other established techniques for perioperative imaging, with echocardiography maintaining its central role in assessment, and enhances direct surgical evaluation. This additive morphological and functional information holds the potential for improving selection of patients, surgical planning, subsequent surgical repair, and hopefully the subsequent outcomes.



Circ Cardiovasc Imaging: 07 Nov 2021:CIRCIMAGING121013134; epub ahead of print
Tretter JT, Izawa Y, Spicer DE, Okada K, ... Quintessenza JA, Mori S
Circ Cardiovasc Imaging: 07 Nov 2021:CIRCIMAGING121013134; epub ahead of print | PMID: 34743527
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Impact:
Abstract

Clinical Value of Stress Transaortic Flow Rate During Dobutamine Echocardiography in Reduced Left Ventricular Ejection Fraction, Low-Gradient Aortic Stenosis: A Multicenter Study.

Vamvakidou A, Annabi MS, Pibarot P, Plonska-Gosciniak E, ... Flachskampf FA, Senior R
Background
Low rest transaortic flow rate (FR) has been shown previously to predict mortality in low-gradient aortic stenosis. However limited prognostic data exists on stress FR during low-dose dobutamine stress echocardiography. We aimed to assess the value of stress FR for the detection of aortic valve stenosis (AS) severity and the prediction of mortality.
Methods
This is a multicenter cohort study of patients with reduced left ventricular ejection fraction and low-gradient aortic stenosis (aortic valve area <1 cm2 and mean gradient <40 mm Hg) who underwent low-dose dobutamine stress echocardiography to identify the AS severity and presence of flow reserve. The outcome assessed was all-cause mortality.
Results
Of the 287 patients (mean age, 75±10 years; males, 71%; left ventricular ejection fraction, 31±10%) over a mean follow-up of 24±30 months there were 127 (44.3%) deaths and 147 (51.2%) patients underwent aortic valve intervention. Higher stress FR was independently associated with reduced risk of mortality (hazard ratio, 0.97 [95% CI, 0.94-0.99]; P=0.01) after adjusting for age, chronic kidney disease, heart failure symptoms, aortic valve intervention, and rest left ventricular ejection fraction. The minimum cutoff for prediction of mortality was stress FR 210 mL/s. Following adjustment to the same important clinical and echocardiographic parameters, among the three criteria of AS severity during stress, ie, the guideline definition of aortic valve area <1cm2 and aortic valve mean gradient ≥40 mm Hg, or aortic valve mean gradient ≥40 mm Hg, or the novel definition of aortic valve area <1 cm2 at stress FR ≥210 mL/s, only the latter was independently associated with mortality (hazard ratio, 1.72 [95% CI, 1.05-2.82]; P=0.03). Furthermore aortic valve area <1cm2 at stress FR ≥210 mL/s was the only severe aortic stenosis criterion that was associated with improved outcome following aortic valve intervention (P<0.001). Guideline-defined stroke volume flow reserve did not predict mortality.
Conclusions
Stress FR during low-dose dobutamine stress echocardiography was useful for the detection of both AS severity and flow reserve and was associated with improved prediction of outcome following aortic valve intervention.



Circ Cardiovasc Imaging: 07 Nov 2021:CIRCIMAGING121012809; epub ahead of print
Vamvakidou A, Annabi MS, Pibarot P, Plonska-Gosciniak E, ... Flachskampf FA, Senior R
Circ Cardiovasc Imaging: 07 Nov 2021:CIRCIMAGING121012809; epub ahead of print | PMID: 34743529
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Impact:
Abstract

Potential novel imaging targets of inflammation in cardiac sarcoidosis.

Park J, Young BD, Miller EJ
Cardiac sarcoidosis (CS) is an inflammatory disease with high morbidity and mortality, with a pathognomonic feature of non-caseating granulomatous inflammation. While 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a well-established modality to image inflammation and diagnose CS, there are limitations to its specificity and reproducibility. Imaging focused on the molecular processes of inflammation including the receptors and cellular microenvironments present in sarcoid granulomas provides opportunities to improve upon FDG-PET imaging for CS. This review will highlight the current limitations of FDG-PET imaging for CS while discussing emerging new nuclear imaging molecular targets for the imaging of cardiac sarcoidosis.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 02 Nov 2021; epub ahead of print
Park J, Young BD, Miller EJ
J Nucl Cardiol: 02 Nov 2021; epub ahead of print | PMID: 34734365
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Impact:
Abstract

Effect of nitroglycerin on splanchnic and pulmonary blood volume.

Okamoto LE, Dupont WD, Biaggioni I, Kronenberg MW, Wright AK
Background
Sublingual nitroglycerin (SL NTG) is useful for treating acute decompensated heart failure, possibly by increasing splanchnic capacitance and reducing left ventricular (LV) preload. We evaluated a radionuclide method to study these effects, initially in subjects without heart failure.
Methods and results
Red blood cells were labelled by an in vitro method. Abdominal and chest images were obtained at rest, showing relative regional blood volumes. The abdomen was then re-imaged during progressive escalation of intrathoracic pressure using continuous positive airway pressure to assess baseline splanchnic capacitance (pressure-volume relationship, PVR) and compliance (slope of PVR). The procedure was repeated after 0.6 mg SL NTG, followed by chest images. Relative splanchnic blood volume increased at rest after SL NTG (P < .002), signifying an increase in splanchnic capacitance. The slope of the splanchnic PVR decreased in proportion to the baseline PVR (P = .0014), signifying increased compliance. The relative pulmonary blood volume decreased in proportion to the increase in splanchnic blood volume (P = .01).
Conclusions
A semi-quantitative radionuclide method demonstrated the effect of SL NTG for increasing splanchnic capacitance and compliance, with a proportional decrease in pulmonary blood volume. These data may be applied to quantitatively evaluate the importance of splanchnic vasodilation as a mechanism of LV preload reduction in the treatment of heart failure.
Clinical trials registration
NCT02425566.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 01 Nov 2021; epub ahead of print
Okamoto LE, Dupont WD, Biaggioni I, Kronenberg MW, Wright AK
J Nucl Cardiol: 01 Nov 2021; epub ahead of print | PMID: 34729682
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Impact:
Abstract

Comparison of diabetes to other prognostic predictors among patients referred for cardiac stress testing: A contemporary analysis from the REFINE SPECT Registry.

Han D, Rozanski A, Gransar H, Tzolos E, ... Berman DS, Slomka PJ
Background
Diabetes mellitus (DM) is increasingly prevalent among contemporary populations referred for cardiac stress testing, but its potency as a predictor for major adverse cardiovascular events (MACE) vs other clinical variables is not well delineated.
Methods and results
From 19,658 patients who underwent SPECT-MPI, we identified 3122 patients with DM without known coronary artery disease (CAD) (DM+/CAD-) and 3564 without DM with known CAD (DM-/CAD+). Propensity score matching was used to control for the differences in characteristics between DM+/CAD- and DM-/CAD+ groups. There was comparable MACE in the matched DM+/CAD- and DM-/CAD+ groups (HR 1.15, 95% CI 0.97-1.37). By Chi-square analysis, type of stress (exercise or pharmacologic), total perfusion deficit (TPD), and left ventricular function were the most potent predictors of MACE, followed by CAD and DM status. The combined consideration of mode of stress, TPD, and DM provided synergistic stratification, an 8.87-fold (HR 8.87, 95% CI 7.27-10.82) increase in MACE among pharmacologically stressed patients with DM and TPD > 10% (vs non-ischemic, exercised stressed patients without DM).
Conclusions
Propensity-matched patients with DM and no known CAD have similar MACE risk compared to patients with known CAD and no DM. DM is synergistic with mode of stress testing and TPD in predicting the risk of cardiac stress test patients.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 09 Nov 2021; epub ahead of print
Han D, Rozanski A, Gransar H, Tzolos E, ... Berman DS, Slomka PJ
J Nucl Cardiol: 09 Nov 2021; epub ahead of print | PMID: 34757571
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Impact:
Abstract

Pulmonary perfusion and NYHA classification improve after cardiac resynchronization therapy.

Al-Mashat M, Borgquist R, Carlsson M, Arheden H, Jögi J
Background
Evaluation of cardiac resynchronization therapy (CRT) often includes New York Heart Association (NYHA) classification, and echocardiography. However, these measures have limitations. Perfusion gradients from ventilation/perfusion single-photon emission computed tomography (V/P SPECT) are related to left-heart filling pressures and have been validated against invasive right-heart catheterization. The aim was to assess if changes in perfusion gradients are associated with improvements in heart failure (HF) symptoms after CRT, and if they correlate with currently used diagnostic methods in the follow-up of patients with HF after receiving CRT.
Methods and results
Nineteen patients underwent V/P SPECT, echocardiography, NYHA classification, and the quality-of-life scoring system \"Minnesota living with HF\" (MLWHF), before and after CRT. CRT caused improvement in perfusion gradients from V/P SPECT which were associated with improvements in NYHA classification (P = .0456), whereas improvements in end-systolic volume (LVESV) from echocardiography were not. After receiving CRT, the proportion of patients who improved was lower using LVESV (n = 7/19, 37%) than perfusion gradients (n = 13/19, 68%). Neither change in perfusion gradients nor LVESV was associated with changes in MLWHF (P = 1.0, respectively).
Conclusions
Measurement of perfusion gradients from V/P SPECT is a promising quantitative user-independent surrogate measure of left-sided filling pressure in the assessment of CRT response in patients with HF.

© 2021. The Author(s).

J Nucl Cardiol: 07 Nov 2021; epub ahead of print
Al-Mashat M, Borgquist R, Carlsson M, Arheden H, Jögi J
J Nucl Cardiol: 07 Nov 2021; epub ahead of print | PMID: 34750725
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Impact:
Abstract

Prognostic implication of myocardial perfusion and contractile reserve in end-stage renal disease: A direct comparison of myocardial perfusion scintigraphy and dobutamine stress echocardiography.

Bautz J, Stypmann J, Reiermann S, Pavenstädt HJ, ... Reuter S, Schäfers M
Background
We aimed to compare the prognostic value of myocardial perfusion scintigraphy (MPS) and dobutamine stress echocardiography (DSE) in patients with end-stage renal disease (ESRD) without known coronary artery disease.
Methods
Two-hundred twenty-nine ESRD patients who applied for kidney transplantation at our centre were prospectively evaluated by MPS and DSE. The primary endpoint was a composite of myocardial infarction (MI) or all-cause mortality. The secondary endpoint included MI or coronary revascularization (CR) not triggered by MPS or DSE at baseline.
Results
MPS detected reversible ischemia in 31 patients (13.5%) and fixed perfusion defects in 13 (5.7%) patients. DSE discovered stress-induced wall motion abnormalities (WMAs) in 28 (12.2%) and at rest in 18 (7.9%) patients. MPS and DSE results agreed in 85.6% regarding reversible defects (κ = 0.358; P < .001) and in 90.8% regarding fixed defects (κ = 0.275; P < .001). Coronary angiography detected relevant stenosis > 50% in only 15 of 38 patients (39.5%) with pathological findings in MPS and/or DSE. At a median follow-up of 8 years and 10 months, the primary endpoint occurred in 70 patients (30.6%) and the secondary endpoint in 24 patients (10.5%). The adjusted Cox hazard ratios (HRs) for the primary endpoint were 1.77 (95% CI 1.02-3.08; P = .043) for perfusion defects in MPS and 1.36 (95% CI 0.78-2.37; P = ns) for WMA in DSE. The secondary endpoint was significantly correlated with the findings of both modalities, MPS (HR 3.21; 95% CI 1.35-7.61; P = .008) and DSE (HR 2.67; 95% CI 1.15-6.20; P = .022).
Conclusion
Perfusion defects in MPS are a stronger determinant of all-cause mortality, MI and the need for future CR compared with WMAs in DSE. Given the complementary functional information provided by MPS vs DSE, results are sometimes contradictory, which may indicate differences in the underlying pathophysiology.

© 2021. The Author(s).

J Nucl Cardiol: 07 Nov 2021; epub ahead of print
Bautz J, Stypmann J, Reiermann S, Pavenstädt HJ, ... Reuter S, Schäfers M
J Nucl Cardiol: 07 Nov 2021; epub ahead of print | PMID: 34750727
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Impact:
Abstract

External validation of the CRAX2MACE model in an Italian cohort of patients with suspected coronary artery disease undergoing stress myocardial perfusion imaging.

Megna R, Petretta M, Assante R, Zampella E, ... Acampa W, Cuocolo A
Background
Prevention and development of diagnostic and therapeutic techniques reduced morbidity and mortality for coronary artery disease (CAD). In this context, the cardiovascular risk assessment for major adverse cardiac events (MACE) at 2-year (CRAX2MACE) model for prediction of 2-year major adverse cardiac events was developed. We performed an external validation of this model.
Methods
We included 1003 patients with suspected CAD undergoing stress-rest single-photon emission computed tomography myocardial perfusion imaging at our academic center between March 2015 and April 2019.
Results
Considering the occurrence of MACE (death from any cause, acute myocardial infarction, or late coronary revascularization), for the CRAX2MACE model the area under the receiver operating characteristic curve was 0.612 and the Brier score was 0.061. The Hosmer-Lemeshow test estimated a non-optimal fit (χ2 28, P < .001). Considering only hard events (cardiac death, acute myocardial infarction), the external validation of the CRAX2MACE model revealed a Brier score of 0.053 and an area under the receiver operating characteristic curve of 0.621. Hosmer-Lemeshow test was calculated by deciles and showed a poor fit (χ2 31, P < .001).
Conclusion
CRAX2MACE model had a limited value for predicting 2-year major adverse cardiovascular events in an external validation cohort of patients with suspected CAD.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 02 Nov 2021; epub ahead of print
Megna R, Petretta M, Assante R, Zampella E, ... Acampa W, Cuocolo A
J Nucl Cardiol: 02 Nov 2021; epub ahead of print | PMID: 34734366
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Impact:
Abstract

Prognostic value of cardiac inflammation in ST-segment elevation myocardial infarction: A F-fluorodeoxyglucose PET/CT study.

Xi XY, Liu Z, Wang LF, Yang MF
Background
18F-fluorodeoxyglucose (FDG) imaging is used to detect cardiac inflammation and predict functional outcome in acute myocardial infarction (MI). However, data on the correlation of post-MI acute cardiac inflammation evaluated by 18F-FDG imaging and major adverse cardiac events (MACE) are limited. Therefore, we sought to explore the prognostic value of cardiac 18F-FDG imaging in patients with acute ST-segment elevation MI (STEMI).
Methods
Thirty-six patients with STEMI underwent 18F-FDG positron emission tomography/computed tomography (PET/CT) 5 days after primary percutaneous coronary intervention. 18F-FDG activity in infarcted and remote regions, as well as peri-coronary adipose tissue (PCAT), were measured and expressed as the maximum standardized uptake value (SUVmax). Patients were followed to determine the occurrence of MACE.
Results
The infarcted myocardium had a higher 18F-FDG intensity than the remote area. Moreover, the PCAT of culprit coronary arteries showed a higher 18F-FDG uptake than that of non-culprit arteries. Multivariate Cox regression analysis showed that increased SUVmax of PCAT [HR 5.198; 95% CI (1.058, 25.537), P = .042] was independently associated with a higher risk of MACE.
Conclusions
Enhanced PCAT activity after acute MI is related to the occurrence of MACE, and 18F-FDG PET/CT plays a promising role in providing prognostic information in patients with STEMI.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 11 Nov 2021; epub ahead of print
Xi XY, Liu Z, Wang LF, Yang MF
J Nucl Cardiol: 11 Nov 2021; epub ahead of print | PMID: 34773185
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Impact:
Abstract

Impact of residual subtraction on myocardial blood flow and reserve estimates from rapid dynamic PET protocols.

Poitrasson-Rivière A, Moody JB, Renaud JM, Hagio T, ... Ficaro EP, Murthy VL
Background
13N-ammonia and 18F-flurpiridaz require longer delays between rest and stress studies to allow for decay, lowering clinical throughput. In this study, we investigated the impact of residual subtraction on MBF and MFR estimates, as well as its effects on diagnostic accuracy.
Methods
We retrospectively analyzed 63 patients who underwent a dynamic ammonia rest/stress study and 231 patients from the flurpiridaz 301 trial. Residual subtraction was performed by subtracting the mean pre-injection activity in each sampled region from that region\'s time activity curve. Corrected and uncorrected MBF and MFR were analyzed. Diagnostic accuracy was compared to quantitative coronary angiograms (QCA) for the flurpiridaz population.
Results
With delays between injections above 3 half-lives, and a doubled stress dose, residual activity did not meaningfully increase ammonia MBF (< 5%). For shorter injection delays, stress MBF was overestimated by 13.6% ± 5.0% (P < .001). Residual activity had a large effect on flurpiridaz stress MBF, overestimating it by 37.9% ± 23.2% (P < .001). Comparison to QCA showed a significant improvement in AUC with residual subtraction (from 0.748 to 0.831, P = .001). MFR yielded similar results.
Conclusions
Accounting for residual activity has a marked impact on stress MBF and MFR and improves diagnostic accuracy relative to QCA.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 14 Nov 2021; epub ahead of print
Poitrasson-Rivière A, Moody JB, Renaud JM, Hagio T, ... Ficaro EP, Murthy VL
J Nucl Cardiol: 14 Nov 2021; epub ahead of print | PMID: 34780036
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Impact:
Abstract

Incremental value of F-FDG cardiac PET imaging over dobutamine stress echocardiography in predicting myocardial ischemia in patients with suspected coronary artery disease.

Zampella E, Assante R, Acampa W, Gaudieri V, ... Petretta M, Cuocolo A
Background
To assess the incremental value of 18F-fluorodeoxyglucose (FDG) cardiac positron emission tomography (PET) over dobutamine stress echocardiography (DSE) in predicting myocardial ischemia in patients with suspected coronary artery disease (CAD).
Methods
Forty-one patients with suspected CAD underwent within 7 days apart rest-stress cardiac PET with 82Rb and DSE followed by cardiac 18F-FDG PET imaging. 18F-FDG images were scored on a 0 (no discernible uptake) to 2 (intense uptake) scale. Logistic regression analysis was performed to identify predictors of stress-induced ischemia. The incremental value of 18F-FDG PET over DSE in detecting ischemia at 82Rb PET cardiac imaging was assessed by the likelihood ratio chi-square and net reclassification index.
Results
On 82Rb-PET imaging, myocardial ischemia (ischemic total perfusion defect ≥ 5%) was detected in 20 (49%) patients. Inducible ischemia was found in 22 (54%) patients on DSE (biphasic or worsening response pattern in ≥ 1 segment) and in 21 (51%) patients on 18F-FDG PET (uptake score of 2 in ≥ 1 segment). 18F-FDG PET resulted as statistically significant predictor of ischemia on 82Rb-PET. The addition of 18F-FDG PET to DSE increased the likelihood of ischemia on 82Rb-PET (P < .05). 18F-FDG PET was able to reclassify the probability of stress-induced myocardial ischemia on both patient and vessel analyses.
Conclusion
18F-FDG PET performed after dobutamine stress test may provide incremental value to DSE in the evaluation of myocardial ischemia. These results suggest that stress-induced myocardial ischemia can be imaged directly using 18F-FDG PET after dobutamine stress test.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 16 Nov 2021; epub ahead of print
Zampella E, Assante R, Acampa W, Gaudieri V, ... Petretta M, Cuocolo A
J Nucl Cardiol: 16 Nov 2021; epub ahead of print | PMID: 34791621
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Impact:
Abstract

Coronary vasomotor dysfunction portends worse outcomes in patients with breast cancer.

Divakaran S, Caron JP, Zhou W, Hainer J, ... Nohria A, Di Carli MF
Background
Impaired MFR in the absence of flow-limiting CAD is associated with adverse events. Cardiovascular disease is an important cause of morbidity and mortality in patients with breast cancer. We sought to test the utility of MFR to predict outcomes in a cohort of patients with breast cancer.
Methods
We retrospectively studied consecutive patients with breast cancer or breast cancer survivors who underwent cardiac stress PET imaging from 2006 to 2017 at Brigham and Women\'s Hospital. Patients with a history of clinically overt CAD, LVEF < 45%, or abnormal myocardial perfusion were excluded. Subjects were followed from time of PET to the occurrence of a first major adverse cardiovascular event (MACE) and all-cause death.
Results
The final cohort included 87 patients (median age 69.0 years, 98.9% female, mean MFR 2.05). Over a median follow-up of 7.6 years after PET, the lowest MFR tertile was associated with higher cumulative incidence of MACE (adjusted subdistribution hazard ratio 4.91; 95% CI 1.68-14.38; p = 0.004) when compared with the highest MFR tertile.
Conclusions
In patients with breast cancer, coronary vasomotor dysfunction was associated with incident cardiovascular events. MFR may have potential as a risk stratification biomarker among patients with/survivors of breast cancer.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 23 Nov 2021; epub ahead of print
Divakaran S, Caron JP, Zhou W, Hainer J, ... Nohria A, Di Carli MF
J Nucl Cardiol: 23 Nov 2021; epub ahead of print | PMID: 34820770
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Impact:
Abstract

Anti-inflammatory effect of rosuvastatin in patients with HIV infection: An FDG-PET pilot study.

Boczar KE, Faller E, Zeng W, Wang J, ... MacPherson P, Dwivedi G
Aims
This study aimed to evaluate markers of systemic as well as imaging markers of inflammation in the ascending aorta, bone marrow, and spleen measured by 18F-FDG PET/CT, in HIV+ patients at baseline and following therapy with rosuvastatin.
Methods and results
Of the 35 HIV+ patients enrolled, 17 were randomized to treatment with 10 mg/day rosuvastatin and 18 to usual care for 6 months. An HIV- control cohort was selected for baseline comparison of serum inflammatory markers and monocyte markers of inflammation. 18F-FDG-PET/CT imaging of bone marrow, spleen, and thoracic aorta was performed in the HIV+ cohort at baseline and 6 months. While CD14++CD16- and CCR2 expressions were reduced, serum levels of IL-7, IL-8, and MCP-1 were elevated in the HIV+ population compared to the controls. There was a significant drop in FDG uptake in the bone marrow (TBRmax), spleen (SUVmax) and thoracic aortic (TBRmax) in the statin-treated group compared to the control group (bone marrow: - 10.3 ± 16.9% versus 5.0 ± 18.9%, p = .0262; spleen: - 9.8 ± 20.3% versus 11.3 ± 28.8%, p = .0497; thoracic aorta: - 19.1 ± 24.2% versus 4.3 ± 15.4%, p = .003).
Conclusions
HIV+ patients had significantly markers of systemic inflammation including monocyte activation. Treatment with low-dose rosuvastatin in the HIV+ cohort significantly reduced bone marrow, spleen and thoracic aortic FDG uptake.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 23 Nov 2021; epub ahead of print
Boczar KE, Faller E, Zeng W, Wang J, ... MacPherson P, Dwivedi G
J Nucl Cardiol: 23 Nov 2021; epub ahead of print | PMID: 34820771
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Impact:
Abstract

Non-invasive Imaging in Coronary Syndromes - Recommendations of the European Association of Cardiovascular Imaging and the American Society of Echocardiography, in Collaboration with the American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance.

Edvardsen T, Asch FM, Davidson B, Delgado V, ... Lindner JR, Popescu BA
Coronary artery disease (CAD) is one of the major causes of mortality and morbidity worldwide, with a high socioeconomic impact.(1) Non-invasive imaging modalities play a fundamental role in the evaluation and management of patients with known or suspected CAD. Imaging end-points have served as surrogate markers in many observational studies and randomized clinical trials that evaluated the benefits of specific therapies for CAD.(2) A number of guidelines and recommendations have been published about coronary syndromes by cardiology societies and associations, but have not focused on the excellent opportunities with cardiac imaging. The recent European Society of Cardiology (ESC) 2019 guideline on chronic coronary syndromes (CCS) and 2020 guideline on acute coronary syndromes in patients presenting with non-ST-segment elevation (NSTE-ACS) highlight the importance of non-invasive imaging in the diagnosis, treatment, and risk assessment of the disease.(3)(4) The purpose of the current recommendations is to present the significant role of non-invasive imaging in coronary syndromes in more detail. These recommendations have been developed by the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE), in collaboration with the American Society of Nuclear Cardiology, the Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance, all of which have approved the final document.

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: 08 Nov 2021; epub ahead of print
Edvardsen T, Asch FM, Davidson B, Delgado V, ... Lindner JR, Popescu BA
Eur Heart J Cardiovasc Imaging: 08 Nov 2021; epub ahead of print | PMID: 34751391
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Impact:
Abstract

Prognostic values of exercise echocardiography and cardiopulmonary exercise testing in patients with primary mitral regurgitation.

Coisne A, Aghezzaf S, Galli E, Mouton S, ... Donal E, Montaigne D
Aims
To compare the clinical significance of exercise echocardiography (ExE) and cardiopulmonary exercise testing (CPX) in patients with ≥moderate primary mitral regurgitation (MR) and discrepancy between symptoms and MR severity.
Methods and results
Patients consulting for ≥moderate discordant primary MR prospectively underwent low (25 W) ExE, peak ExE, and CPX within 2 months in Lille and Rennes University Hospital. Patients with Class I recommendation for surgical MR correction were excluded. Changes in MR severity, systolic pulmonary artery pressure (SPAP), left ventricular ejection fraction (LVEF), and tricuspid annular plane systolic excursion were evaluated during ExE. Patients were followed for major events (ME): cardiovascular death, acute heart failure, or mitral valve surgery. Among 128 patients included, 22 presented mild-to-moderate, 61 moderate-to-severe, and 45 severe MR. Unlike MR variation, SPAP and LVEF were successfully assessed during ExE in most patients. Forty-one patients (32%) displayed reduced aerobic capacity (peak VO2 < 80% of predicted value) with cardiac limitation in 28 (68%) and muscular or respiratory limitation in the 13 others (32%). ME occurred in 61 patients (47.7%) during a mean follow-up of 27 ± 21 months. Twenty-five Watts SPAP [hazard ratio (HR) (95% confidence interval, CI) = 1.03 (1.01-1.06), P = 0.003] and reduced aerobic capacity [HR (95% CI) = 1.74 (1.03-2.95), P = 0.04] were independently predictive of ME, even after adjustment for MR severity. The cut-off of 55 mmHg for 25 W SPAP showed the best accuracy to predict ME (area under the curve = 0.60, P = 0.05).
Conclusion
In patients with ≥moderate primary MR and discordant symptoms, 25 W exercise pulmonary hypertension, defined as an SPAP ≥55 mmHg, and poor aerobic capacity during CPX are independently associated with adverse events.

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: 08 Nov 2021; epub ahead of print
Coisne A, Aghezzaf S, Galli E, Mouton S, ... Donal E, Montaigne D
Eur Heart J Cardiovasc Imaging: 08 Nov 2021; epub ahead of print | PMID: 34751769
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Impact:
Abstract

Applications of multimodality imaging for left atrial catheter ablation.

Roney CH, Sillett C, Whitaker J, Lemus JAS, ... Williams SE, Niederer SA
Atrial arrhythmias, including atrial fibrillation and atrial flutter, may be treated through catheter ablation. The process of atrial arrhythmia catheter ablation, which includes patient selection, pre-procedural planning, intra-procedural guidance, and post-procedural assessment, is typically characterized by the use of several imaging modalities to sequentially inform key clinical decisions. Increasingly, advanced imaging modalities are processed via specialized image analysis techniques and combined with intra-procedural electrical measurements to inform treatment approaches. Here, we review the use of multimodality imaging for left atrial ablation procedures. The article first outlines how imaging modalities are routinely used in the peri-ablation period. We then describe how advanced imaging techniques may inform patient selection for ablation and ablation targets themselves. Ongoing research directions for improving catheter ablation outcomes by using imaging combined with advanced analyses for personalization of ablation targets are discussed, together with approaches for their integration in the standard clinical environment. Finally, we describe future research areas with the potential to improve catheter ablation outcomes.

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

Eur Heart J Cardiovasc Imaging: 07 Nov 2021; epub ahead of print
Roney CH, Sillett C, Whitaker J, Lemus JAS, ... Williams SE, Niederer SA
Eur Heart J Cardiovasc Imaging: 07 Nov 2021; epub ahead of print | PMID: 34747450
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Impact:
Abstract

Right heart chambers geometry and function in patients with the atrial and the ventricular phenotypes of functional tricuspid regurgitation.

Florescu DR, Muraru D, Florescu C, Volpato V, ... Parati G, Badano LP
Aims
Atrial functional tricuspid regurgitation (A-FTR) is a recently defined phenotype of functional tricuspid regurgitation (FTR) associated with persistent/permanent atrial fibrillation. Differently from the classical ventricular form of FTR (V-FTR), patients with A-FTR might present with severely dilated right atrium and tricuspid annulus (TA), and with preserved right ventricular (RV) size and systolic function. However, the geometry and function of the right ventricle, right atrium, and TA in patients with A-FTR and V-FTR remain to be systematically evaluated. Accordingly, we sought to: (i) study the geometry and function of the right ventricle, right atrium, and TA in A-FTR by two- and three-dimensional transthoracic echocardiography; and (ii) compare them with those found in V-FTR.
Methods and results
We prospectively analysed 113 (44 men, age 68 ± 18 years) FTR patients (A-FTR = 55 and V-FTR = 58) that were compared to two groups of age- and sex-matched controls to develop the respective Z-scores. Severity of FTR was similar in A-FTR and V-FTR patients. Z-scores of RV size were significantly larger, and those of RV function were significantly lower in V-FTR than in A-FTR (P < 0.001 for all). The right atrium was significantly enlarged in both A-FTR and V-FTR compared to controls (P < 0.001, Z-scores > 2), with similar right atrial (RA) maximum volume (RAVmax) between A-FTR and V-FTR (P = 0.2). Whereas, the RA minimum volumes (RAVmin) were significantly larger in A-FTR than in V-FTR (P = 0.001).
Conclusion
Despite similar degrees of FTR and RAVmax size, A-FTR patients show larger RAVmin and smaller TA areas than V-FTR patients. Conversely, V-FTR patients show dilated, more elliptic and dysfunctional right ventricle than A-FTR patients.

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

Eur Heart J Cardiovasc Imaging: 07 Nov 2021; epub ahead of print
Florescu DR, Muraru D, Florescu C, Volpato V, ... Parati G, Badano LP
Eur Heart J Cardiovasc Imaging: 07 Nov 2021; epub ahead of print | PMID: 34747460
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Impact:
Abstract

Myocarditis following COVID-19 vaccination: magnetic resonance imaging study.

Shiyovich A, Witberg G, Aviv Y, Eisen A, ... Kornowski R, Hamdan A
Aims
To describe the cardiac magnetic resonance (CMR) imaging findings of patients who developed myocarditis following messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccination.
Methods and results
The present study retrospectively evaluated patients with clinically adjudicated myocarditis within 42 days of the first Pfizer-BNT162b2 mRNA COVID-19 vaccination, between 20 December 2020 and 24 May 2021 who underwent CMR. A total of 15 out 54 patients (28%) with myocarditis underwent a CMR and were included, 100% males, median age of 32 years (interquartile range = 22.5-40). Most patients presented with chest pain (87%) and had an abnormal electrocardiogram (79%). The severity of the disease was mild in 67% and intermediate in 33%. All patients survived and one patient was readmitted during the study period. CMR was performed at a median of 65 days (range 3-130 days) following diagnosis. Median ejection fraction was 58% (range 51-74%) global- and regional wall motion abnormalities were present in one and three patients, respectively. Native T1 was available in 13/15 patients (2/3 in 3 T and 11/12 in the 1.5 T), with increased values among 6/13. Late gadolinium enhancement (LGE) was found among 13/15 patients with a median of 2% (range 0-15%) with inferolateral wall being the most common location (8/13). The patterns of the LGE were: mid-wall in six patients; epicardial in five patients; and mid-wall and epicardial in two patients.
Conclusions
Among patients who were diagnosed with post-vaccination clinical myocarditis, CMR imaging findings are mild and consistent with \'classical myocarditis\'. The short-term clinical course and outcomes were favourable.

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 Nov 2021; epub ahead of print
Shiyovich A, Witberg G, Aviv Y, Eisen A, ... Kornowski R, Hamdan A
Eur Heart J Cardiovasc Imaging: 04 Nov 2021; epub ahead of print | PMID: 34739045
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Impact:
Abstract

Multimodality imaging approach to left ventricular dysfunction in diabetes: an expert consensus document from the European Association of Cardiovascular Imaging.

Marwick TH, Gimelli A, Plein S, Bax JJ, ... Neglia D, Stankovic I
Heart failure (HF) is among the most important and frequent complications of diabetes mellitus (DM). The detection of subclinical dysfunction is a marker of HF risk and presents a potential target for reducing incident HF in DM. Left ventricular (LV) dysfunction secondary to DM is heterogeneous, with phenotypes including predominantly systolic, predominantly diastolic, and mixed dysfunction. Indeed, the pathogenesis of HF in this setting is heterogeneous. Effective management of this problem will require detailed phenotyping of the contributions of fibrosis, microcirculatory disturbance, abnormal metabolism, and sympathetic innervation, among other mechanisms. For this reason, an imaging strategy for the detection of HF risk needs to not only detect subclinical LV dysfunction (LVD) but also characterize its pathogenesis. At present, it is possible to identify individuals with DM at increased risk HF, and there is evidence that cardioprotection may be of benefit. However, there is insufficient justification for HF screening, because we need stronger evidence of the links between the detection of LVD, treatment, and improved outcome. This review discusses the options for screening for LVD, the potential means of identifying the underlying mechanisms, and the pathways to treatment.

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

Eur Heart J Cardiovasc Imaging: 04 Nov 2021; epub ahead of print
Marwick TH, Gimelli A, Plein S, Bax JJ, ... Neglia D, Stankovic I
Eur Heart J Cardiovasc Imaging: 04 Nov 2021; epub ahead of print | PMID: 34739054
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Impact:
Abstract

Tafamidis treatment delays structural and functional changes of the left ventricle in patients with transthyretin amyloid cardiomyopathy.

Rettl R, Mann C, Duca F, Dachs TM, ... Eslam RB, Bonderman D
Aims
Tafamidis improves outcomes in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). However, it is not yet known whether tafamidis affects cardiac amyloid deposition and structural changes in the myocardium. We aimed to determine disease-modifying effects on myocardial amyloid progression and to identify imaging parameters that could be applied for specific therapy monitoring.
Methods and results
ATTR-CM patients underwent serial cardiac magnetic resonance (CMR) imaging using T1 mapping techniques to derive extracellular volume (ECV). Patients receiving tafamidis 61 mg (n = 35) or 20 mg (n = 15) once daily showed stable measurements at follow-up (FU) {61 mg: 9.0 [interquartile range (IQR) 7.0-11.0] months, 20 mg: 11.0 (IQR 8.0-18.0) months} in left ventricular (LV) ejection fraction (LVEF; 61 mg: 47.6% vs. 47.5%, P = 0.935; 20 mg: 52.4% vs. 52.1%, P = 0.930), LV mass index (LVMI; 61 mg: 110.2 vs. 106.2 g/m2, P = 0.304; 20 mg: 114.5 vs. 115.4 g/m2, P = 0.900), and ECV (61 mg: 47.5% vs. 47.7%, P = 0.861; 20 mg: 56.7% vs. 57.5%, P = 0.759), whereas treatment-naïve ATTR-CM patients (n = 19) had clear signs of disease progression at the end of the observation period [12.0 (IQR 10.0-21.0) months; LVEF: 53.3% vs. 45.7%, P = 0.031; LVMI: 98.9 vs. 106.9 g/m2, P = 0.027; ECV: 49.3% vs. 54.6%, P = 0.023]. Between-group comparison at FU revealed positive effects in tafamidis 61 mg-treated compared to treatment-naïve patients (LVEF: P = 0.035, LVMI: P = 0.036, ECV: P = 0.030), while those treated with 20 mg showed no difference in the above LV measurements when compared with treatment-naïve (P = 0.120, P = 0.287, P = 0.158). However, both treatment groups showed clinically beneficial effects compared to the natural course [61 mg, 6-min walk distance (6-MWD): P = 0.005, N-terminal prohormone of brain natriuretic peptide (NT-proBNP): P = 0.002; 20 mg, 6-MWD: P = 0.023, NT-proBNP: P = 0.003].
Conclusion
Tafamidis delays myocardial amyloid progression in ATTR-CM patients, resulting in structural, functional, and clinical benefits compared to the natural course. Serial CMR including measurement of ECV may be appropriate for disease-specific therapy monitoring.

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

Eur Heart J Cardiovasc Imaging: 10 Nov 2021; epub ahead of print
Rettl R, Mann C, Duca F, Dachs TM, ... Eslam RB, Bonderman D
Eur Heart J Cardiovasc Imaging: 10 Nov 2021; epub ahead of print | PMID: 34788394
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Impact:
Abstract

Atrioventricular and Ventricular Functional Interdependence in Individuals Without Overt Cardiac Disease.

Yoshida Y, Nakanishi K, Daimon M, Ishiwata J, ... Homma S, Komuro I

Background:
Left atrial (LA) and right ventricular (RV) performance play an integral role in the pathophysiology and prognosis of heart failure. We hypothesized that subclinical left ventricular dysfunction adversely affects LA/RV geometry and function even in a preclinical setting. This study aimed to investigate the atrioventricular and ventricular functional interdependence in a community-based cohort without overt cardiovascular disease. Methods and Results Left ventricular global longitudinal strain (LVGLS), RV free-wall longitudinal strain and LA phasic strain were assessed by speckle-tracking echocardiography in 1080 participants (600 men; 62±12 years) between 2014 and 2018. One hundred and forty-three participants (13.2%) had an abnormal LVGLS (>-18.6%). LA reservoir strain, conduit strain, and RV free-wall longitudinal strain were significantly decreased in abnormal LVGLS group compared with normal LVGLS group (all P<0.001). LA and RV dysfunction (LA reservoir strain<31.4% and RVLS>-19.2%) were present in 18.9% and 19.6% of participants with abnormal LVGLS. Decreased LVGLS was associated with worse LA reservoir strain, conduit strain and RV free-wall longitudinal strain (standardized β=-0.20, -0.19 and 0.11 respectively, all P<0.01) independent of cardiovascular risk factors. LA and/or RV dysfunction concomitant with abnormal LVGLS carried significantly increased risk of elevated B-type natriuretic peptide levels (>28.6 pg/mL for men and >44.4 pg/mL for women) compared with normal LVGLS (odds ratio, 2.01; P=0.030).
Conclusions:
LA/RV dysfunction was present in 20% individuals with abnormal LVGLS and multi-chamber impairment was associated with elevated B-type natriuretic peptide level, which may provide valuable insights for a better understanding of atrioventricular and ventricular interdependence and possibly heart failure preventive strategies.




J Am Heart Assoc: 14 Nov 2021:e021624; epub ahead of print
Yoshida Y, Nakanishi K, Daimon M, Ishiwata J, ... Homma S, Komuro I
J Am Heart Assoc: 14 Nov 2021:e021624; epub ahead of print | PMID: 34775816
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Impact:
Abstract

Peak flow measurements in patients with severe aortic stenosis: a prospective comparative study between cardiovascular magnetic resonance 2D and 4D flow and transthoracic echocardiography.

Hälvä R, Vaara SM, Peltonen JI, Kaasalainen TT, ... Kivistö S, Syväranta S
Background
Aortic valve stenosis (AS) is the most prevalent valvular disease in the developed countries. Four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) is an emerging imaging technique, which has been suggested to improve the evaluation of AS severity compared to two-dimensional (2D) flow and transthoracic echocardiography (TTE). We investigated the reliability of CMR 2D flow and 4D flow techniques in measuring aortic transvalvular peak systolic flow in patients with severe AS.
Methods
We prospectively recruited 90 patients referred for aortic valve replacement due to severe AS (73.3 ± 11.3 years, aortic valve area 0.7 ± 0.1 cm2, and 54/36 tricuspid/bicuspid), and 10 non-valvular disease controls. All the patients underwent echocardiography and 2D flow and 4D flow CMR. Peak flow velocity measurements were compared using Wilcoxon signed rank sum test and Bland-Altman analysis.
Results
4D flow underestimated peak flow velocity in the AS group when compared with TTE (bias - 1.1 m/s, limits of agreement ± 1.4 m/s) and 2D flow (bias - 1.2 m/s, limits of agreement ± 1.6 m/s). The differences between values obtained by TTE (median 4.3 m/s, range 2.7-6.1 m/s) and 2D flow (median 4.5 m/s, range 2.9-6.5 m/s) compared to 4D flow (median 3.1 m/s, range 1.7-5.1 m/s) were significant (p < 0.001). The difference between 2D flow and TTE were insignificant (bias 0.07 m/s, limits of agreement ± 1.5 m/s). In non-valvular disease controls, peak flow velocity was measured higher by 4D flow than 2D flow (1.4 m/s, 1.1-1.7 m/s and 1.3 m/s, 1.1-1.5 m/s, respectively; bias 0.2 m/s, limits of agreement ± 0.16 m/s).
Conclusions
CMR 4D flow significantly underestimates systolic peak flow velocity in patients with severe AS. 2D flow, in turn, estimated the AS velocity accurately, with measured peak flow velocities comparable to TTE.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 14 Nov 2021; 23:132
Hälvä R, Vaara SM, Peltonen JI, Kaasalainen TT, ... Kivistö S, Syväranta S
J Cardiovasc Magn Reson: 14 Nov 2021; 23:132 | PMID: 34775954
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Impact:
Abstract

Impaired left atrial reservoir and conduit strain in patients with atrial fibrillation and extensive left atrial fibrosis.

Hopman LHGA, Mulder MJ, van der Laan AM, Demirkiran A, ... Allaart CP, Götte MJW
Background
Atrial fibrillation (AF) is associated with profound structural and functional changes in the atria. In the present study, we investigated the association between left atrial (LA) phasic function and the extent of LA fibrosis using advanced cardiovascular magnetic resonance (CMR) imaging techniques, including 3-dimensional (3D) late gadolinium enhancement (LGE) and feature tracking.
Methods
Patients with paroxysmal and persistent AF (n = 105) underwent CMR in sinus rhythm. LA global reservoir strain, conduit strain and contractile strain were derived from cine CMR images using CMR feature tracking. The extent of LA fibrosis was assessed from 3D LGE images. Healthy subjects underwent CMR and served as controls (n = 19).
Results
Significantly lower LA reservoir strain, conduit strain and contractile strain were found in AF patients, as compared to healthy controls (- 15.9 ± 3.8% vs. - 21.1 ± 3.6% P < 0.001, - 8.7 ± 2.7% vs. - 12.6 ± 2.5% P < 0.001 and - 7.2 ± 2.3% vs. - 8.6 ± 2.2% P = 0.02, respectively). Patients with a high degree of LA fibrosis (dichotomized by the median value) had lower reservoir strain and conduit strain compared to patients with a low degree of LA fibrosis (- 15.0 ± 3.9% vs. - 16.9 ± 3.3%, P = 0.02 and - 7.9 ± 2.7% vs. - 9.5 ± 2.6%, P = 0.01, respectively). In contrast, no difference was found for LA contractile strain (- 7.1 ± 2.4% vs. - 7.4 ± 2.3%, P = 0.55).
Conclusions
Impaired LA reservoir and conduit strain are present in AF patients with extensive atrial fibrosis. Future studies are needed to examine the biologic nature of this association and possible therapeutic implications.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 10 Nov 2021; 23:131
Hopman LHGA, Mulder MJ, van der Laan AM, Demirkiran A, ... Allaart CP, Götte MJW
J Cardiovasc Magn Reson: 10 Nov 2021; 23:131 | PMID: 34758820
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Impact:
Abstract

Atri-U: assisted image analysis in routine cardiovascular magnetic resonance volumetry of the left atrium.

Anastasopoulos C, Yang S, Pradella M, Akinci D\'Antonoli T, ... Sommer G, Abdulkadir A
Background
Artificial intelligence can assist in cardiac image interpretation. Here, we achieved a substantial reduction in time required to read a cardiovascular magnetic resonance (CMR) study to estimate left atrial volume without compromising accuracy or reliability. Rather than deploying a fully automatic black-box, we propose to incorporate the automated LA volumetry into a human-centric interactive image-analysis process.
Methods and results
Atri-U, an automated data analysis pipeline for long-axis cardiac cine images, computes the atrial volume by: (i) detecting the end-systolic frame, (ii) outlining the endocardial borders of the LA, (iii) localizing the mitral annular hinge points and constructing the longitudinal atrial diameters, equivalent to the usual workup done by clinicians. In every step human interaction is possible, such that the results provided by the algorithm can be accepted, corrected, or re-done from scratch. Atri-U was trained and evaluated retrospectively on a sample of 300 patients and then applied to a consecutive clinical sample of 150 patients with various heart conditions. The agreement of the indexed LA volume between Atri-U and two experts was similar to the inter-rater agreement between clinicians (average overestimation of 0.8 mL/m2 with upper and lower limits of agreement of - 7.5 and 5.8 mL/m2, respectively). An expert cardiologist blinded to the origin of the annotations rated the outputs produced by Atri-U as acceptable in 97% of cases for step (i), 94% for step (ii) and 95% for step (iii), which was slightly lower than the acceptance rate of the outputs produced by a human expert radiologist in the same cases (92%, 100% and 100%, respectively). The assistance of Atri-U lead to an expected reduction in reading time of 66%-from 105 to 34 s, in our in-house clinical setting.
Conclusions
Our proposal enables automated calculation of the maximum LA volume approaching human accuracy and precision. The optional user interaction is possible at each processing step. As such, the assisted process sped up the routine CMR workflow by providing accurate, precise, and validated measurement results.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 10 Nov 2021; 23:133
Anastasopoulos C, Yang S, Pradella M, Akinci D'Antonoli T, ... Sommer G, Abdulkadir A
J Cardiovasc Magn Reson: 10 Nov 2021; 23:133 | PMID: 34758821
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Impact:
Abstract

Myocardial changes on 3T cardiovascular magnetic resonance imaging in response to haemodialysis with fluid removal.

Rankin AJ, Mangion K, Lees JS, Rutherford E, ... Roditi G, Mark PB
Background
Mapping of left ventricular (LV) native T1 is a promising non-invasive, non-contrast imaging biomarker. Native myocardial T1 times are prolonged in patients requiring dialysis, but there are concerns that the dialysis process and fluctuating fluid status may confound results in this population. We aimed to assess the changes in cardiac parameters on 3T cardiovascular magnetic resonance (CMR) before and after haemodialysis, with a specific focus on native T1 mapping.
Methods
This is a single centre, prospective observational study in which maintenance haemodialysis patients underwent CMR before and after dialysis (both scans within 24 h). Weight measurement, bio-impedance body composition monitoring, haemodialysis details and fluid intake were recorded. CMR protocol included cine imaging and mapping native T1 and T2.
Results
Twenty-six participants (16 male, 65 ± 9 years) were included in the analysis. The median net ultrafiltration volume on dialysis was 2.3 L (IQR 1.8, 2.5), resulting in a median weight reduction at post-dialysis scan of 1.35 kg (IQR 1.0, 1.9), with a median reduction in over-hydration (as measured by bioimpedance) of 0.75 L (IQR 0.5, 1.4). Significant reductions were observed in LV end-diastolic volume (- 25 ml, p = 0.002), LV stroke volume (- 13 ml, p = 0.007), global T1 (21 ms, p = 0.02), global T2 (- 1.2 ms, p = 0.02) following dialysis. There was no change in LV mass (p = 0.35), LV ejection fraction (p = 0.13) or global longitudinal strain (p = 0.22). On linear regression there was no association between baseline over-hydration (as defined by bioimpedance) and global native T1 or global T2, nor was there an association between the change in over-hydration and the change in these parameters.
Conclusions
Acute changes in cardiac volumes and myocardial native T1 are detectable on 3T CMR following haemodialysis with fluid removal. The reduction in global T1 suggests that the abnormal native T1 observed in patients on haemodialysis is not entirely due to myocardial fibrosis.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 10 Nov 2021; 23:125
Rankin AJ, Mangion K, Lees JS, Rutherford E, ... Roditi G, Mark PB
J Cardiovasc Magn Reson: 10 Nov 2021; 23:125 | PMID: 34758850
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Abstract

Progressive myocardial injury in myotonic dystrophy type II and facioscapulohumeral muscular dystrophy 1: a cardiovascular magnetic resonance follow-up study.

Blaszczyk E, Lim C, Kellman P, Schmacht L, ... Spuler S, Schulz-Menger J
Aim
Muscular dystrophy (MD) is a progressive disease with predominantly muscular symptoms. Myotonic dystrophy type II (MD2) and facioscapulohumeral muscular dystrophy type 1 (FSHD1) are gaining an increasing awareness, but data on cardiac involvement are conflicting. The aim of this study was to determine a progression of cardiac remodeling in both entities by applying cardiovascular magnetic resonance (CMR) and evaluate its potential relation to arrhythmias as well as to conduction abnormalities.
Methods and results
83 MD2 and FSHD1 patients were followed. The participation was 87% in MD2 and 80% in FSHD1. 1.5 T CMR was performed to assess functional parameters as well as myocardial tissue characterization applying T1 and T2 mapping, fat/water-separated imaging and late gadolinium enhancement. Focal fibrosis was detected in 23% of MD2) and 33% of FSHD1 subjects and fat infiltration in 32% of MD2 and 28% of FSHD1 subjects, respectively. The incidence of all focal findings was higher at follow-up. T2 decreased, whereas native T1 remained stable. Global extracellular volume fraction (ECV) decreased similarly to the fibrosis volume while the total cell volume remained unchanged. All patients with focal fibrosis showed a significant increase in left ventricular (LV) and right ventricular (RV) volumes. An increase of arrhythmic events was observed. All patients with ventricular arrhythmias had focal myocardial changes and an increased volume of both ventricles (LV end-diastolic volume (EDV) p = 0.003, RVEDV p = 0.031). Patients with supraventricular tachycardias had a significantly higher left atrial volume (p = 0.047).
Conclusion
We observed a remarkably fast and progressive decline of cardiac morphology and function as well as a progression of rhythm disturbances, even in asymptomatic patients with a potential association between an increase in arrhythmias and progression of myocardial tissue damage, such as focal fibrosis and fat infiltration, exists. These results suggest that MD2 and FSHD1 patients should be carefully followed-up to identify early development of remodeling and potential risks for the development of further cardiac events even in the absence of symptoms. Trial registration ISRCTN, ID ISRCTN16491505. Registered 29 November 2017 - Retrospectively registered, http://www.isrctn.com/ISRCTN16491505.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 07 Nov 2021; 23:130
Blaszczyk E, Lim C, Kellman P, Schmacht L, ... Spuler S, Schulz-Menger J
J Cardiovasc Magn Reson: 07 Nov 2021; 23:130 | PMID: 34743704
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Abstract

Bright-blood and dark-blood phase sensitive inversion recovery late gadolinium enhancement and T1 and T2 maps in a single free-breathing scan: an all-in-one approach.

Kellman P, Xue H, Chow K, Howard J, ... Cole G, Fontana M
Background
Quantitative cardiovascular magnetic resonance (CMR) T1 and T2 mapping are used to detect diffuse disease such as myocardial fibrosis or edema. However, post gadolinium contrast mapping often lacks visual contrast needed for assessment of focal scar. On the other hand, late gadolinium enhancement (LGE) CMR which nulls the normal myocardium has excellent contrast between focal scar and normal myocardium but has poor ability to detect global disease. The objective of this work is to provide a calculated bright-blood (BB) and dark-blood (DB) LGE based on simultaneous acquisition of T1 and T2 maps, so that both diffuse and focal disease may be assessed within a single multi-parametric acquisition.
Methods
The prototype saturation recovery-based SASHA T1 mapping may be modified to jointly calculate T1 and T2 maps (known as multi-parametric SASHA) by acquiring additional saturation recovery (SR) images with both SR and T2 preparations. The synthetic BB phase sensitive inversion recovery (PSIR) LGE may be calculated from the post-contrast T1, and the DB PSIR LGE may be calculated from the post-contrast joint T1 and T2 maps. Multi-parametric SASHA maps were acquired free-breathing (45 heartbeats). Protocols were designed to use the same spatial resolution and achieve similar signal-to-noise ratio (SNR) as conventional motion corrected (MOCO) PSIR. The calculated BB and DB LGE were compared with separate free breathing (FB) BB and DB MOCO PSIR acquisitions requiring 16 and 32 heart beats, respectively. One slice with myocardial infarction (MI) was acquired with all protocols within 4 min.
Results
Multiparametric T1 and T2 maps and calculated BB and DB PSIR LGE images were acquired for patients with subendocardial chronic MI (n = 10), acute MI (n = 3), and myocarditis (n = 1). The contrast-to-noise (CNR) between scar (MI and myocarditis) and remote was 26.6 ± 7.7 and 20.2 ± 7.4 for BB and DB PSIR LGE, and 31.3 ± 10.6 and 21.8 ± 7.6 for calculated BB and DB PSIR LGE, respectively. The CNR between scar and the left ventricualr blood pool was 5.2 ± 6.5 and 29.7 ± 9.4 for conventional BB and DB PSIR LGE, and 6.5 ± 6.0 and 38.6 ± 11.6 for calculated BB and DB PSIR LGE, respectively.
Conclusions
A single free-breathing acquisition using multi-parametric SASHA provides T1 and T2 maps and calculated BB and DB PSIR LGE images for comprehensive tissue characterization.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 07 Nov 2021; 23:126
Kellman P, Xue H, Chow K, Howard J, ... Cole G, Fontana M
J Cardiovasc Magn Reson: 07 Nov 2021; 23:126 | PMID: 34743718
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Abstract

Conformal Left Atrial Appendage Seal Device for Left Atrial Appendage Closure: First Clinical Use.

Sommer RJ, Kim JH, Szerlip M, Chandhok S, ... Kaplan AV, Gray WA
Objectives
The authors report the first clinical experience with the Conformal Left Atrial Appendage Seal (CLAAS) device.
Background
The CLAAS device was designed to address the limitations of first-generation left atrial appendage closure (LAAC) devices by providing an implant that is minimally traumatic, can be deployed in a noncoaxial fashion, and does not require postprocedural oral anticoagulation.
Methods
Patients with atrial fibrillation at high stroke risk (CHA2DS2-VASc score ≥2) were recruited using standard selection criteria. The LAAC procedure was guided by transesophageal echocardiography with patients under general anesthesia. The CLAAS device is composed of a foam cup, with a Nitinol endoskeleton with an expanded polytetrafluoroethylene cover, delivered with a standard delivery system using a tether for full recapture. All patients received dual-antiplatelet therapy for 6 months, followed by aspirin alone. Transesophageal echocardiographic follow-up was scheduled for 45 days and 1 year.
Results
Twenty-two patients (63.7% with CHA2DS2-VASc scores ≥3, 76.2% with HAS-BLED scores ≥3) were enrolled. The device was successfully implanted in 18 patients and unsuccessfully in 4 patients. There were no serious procedural complications. On transesophageal echocardiography performed at 45 days, 1 significant leak (≥5 mm) was seen, which was due to a large posterior lobe not appreciated at the time of implantation, and 1 device-related thrombus was noted, which resolved on oral anticoagulation. There were no periprocedural strokes, major pericardial effusions, or systemic or device embolization.
Conclusions
This first-in-human study demonstrates the clinical feasibility of the CLAAS device for LAAC.

Copyright © 2021. Published by Elsevier Inc.

JACC Cardiovasc Interv: 07 Nov 2021; 14:2368-2374
Sommer RJ, Kim JH, Szerlip M, Chandhok S, ... Kaplan AV, Gray WA
JACC Cardiovasc Interv: 07 Nov 2021; 14:2368-2374 | PMID: 34736735
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Abstract

Accuracy of stroke volume measurement with phase-contrast cardiovascular magnetic resonance in patients with aortic stenosis.

Guzzetti E, Racine HP, Tastet L, Shen M, ... Pibarot P, Beaudoin J
Background
Phase contrast (PC) cardiovascular magnetic resonance (CMR) in the ascending aorta (AAo) is widely used to calculate left ventricular (LV) stroke volume (SV). The accuracy of PC CMR may be altered by turbulent flow. Measurement of SV at another site is suggested in the presence of aortic stenosis, but very few data validates the accuracy or inaccuracy of PC in that setting. Our objective is to compare flow measurements obtained in the AAo and LV outflow tract (LVOT) in patients with aortic stenosis.
Methods
Retrospective analysis of patients with aortic stenosis who had CMR and echocardiography. Patients with mitral regurgitation were excluded. PC in the AAo and LVOT were acquired to derive SV. LV SV from end-systolic and end-diastolic tracings was used as the reference measure. A difference ≥ 10% between the volumetric method and PC derived SVs was considered discordant. Metrics of turbulence and jet eccentricity were assessed to explore the predictors of discordant measurements.
Results
We included 88 patients, 41% with bicuspid aortic valve. LVOT SV was concordant with the volumetric method in 79 (90%) patients vs 52 (59%) patients for AAo SV (p = 0.015). In multivariate analysis, aortic stenosis flow jet angle was a strong predictor of discordant measurement in the AAo (p = 0.003). Mathematical correction for the jet angle improved the concordance from 59 to 91%. Concordance was comparable in patients with bicuspid and trileaflet valves (57% and 62% concordance respectively; p = 0.11). Accuracy of SV measured in the LVOT was not influenced by jet eccentricity. For aortic regurgitation quantification, PC in the AAo had better correlation to volumetric assessments than LVOT PC.
Conclusion
LVOT PC SV in patients with aortic stenosis and eccentric jet might be more accurate compared to the AAo SV. Mathematical correction for the jet angle in the AAo might be another alternative to improve accuracy.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 03 Nov 2021; 23:124
Guzzetti E, Racine HP, Tastet L, Shen M, ... Pibarot P, Beaudoin J
J Cardiovasc Magn Reson: 03 Nov 2021; 23:124 | PMID: 34732204
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Impact:
Abstract

Dark blood cardiovascular magnetic resonance of the heart, great vessels, and lungs using electrocardiographic-gated three-dimensional unbalanced steady-state free precession.

Edelman RR, Leloudas N, Pang J, Koktzoglou I
Background
Recently, we reported a novel neuroimaging technique, unbalanced T1 Relaxation-Enhanced Steady-State (uT1RESS), which uses a tailored 3D unbalanced steady-state free precession (3D uSSFP) acquisition to suppress the blood pool signal while minimizing bulk motion sensitivity. In the present work, we hypothesized that 3D uSSFP might also be useful for dark blood imaging of the chest. To test the feasibility of this approach, we performed a pilot study in healthy subjects and patients undergoing cardiovascular magnetic resonance (CMR).
Main body
The study was approved by the hospital institutional review board. Thirty-one adult subjects were imaged at 1.5 T, including 5 healthy adult subjects and 26 patients (44 to 86 years, 10 female) undergoing a clinically indicated CMR. Breath-holding was used in 29 subjects and navigator gating in 2 subjects. For breath-hold acquisitions, the 3D uSSFP pulse sequence used a high sampling bandwidth, asymmetric readout, and single-shot along the phase-encoding direction, while 3 shots were acquired for navigator-gated scans. To minimize signal dephasing from bulk motion, electrocardiographic (ECG) gating was used to synchronize the data acquisition to the diastolic phase of the cardiac cycle. To further reduce motion sensitivity, the moment of the dephasing gradient was set to one-fifth of the moment of the readout gradient. Image quality using 3D uSSFP was good-to-excellent in all subjects. The blood pool signal in the thoracic aorta was uniformly suppressed with sharp delineation of the aortic wall including two cases of ascending aortic aneurysm and two cases of aortic dissection. Compared with variable flip angle 3D turbo spin-echo, 3D uSSFP showed improved aortic wall sharpness. It was also more efficient, permitting the acquisition of 24 slices in each breath-hold versus 16 slices with 3D turbo spin-echo and a single slice with dual inversion 2D turbo spin-echo. In addition, lung and mediastinal lesions appeared highly conspicuous compared with the low blood pool signals within the heart and blood vessels. In two subjects, navigator-gated 3D uSSFP provided excellent delineation of cardiac morphology in double oblique multiplanar reformations.
Conclusion
In this pilot study, we have demonstrated the feasibility of using ECG-gated 3D uSSFP for dark blood imaging of the heart, great vessels, and lungs. Further study will be required to fully optimize the technique and to assess clinical utility.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 31 Oct 2021; 23:127
Edelman RR, Leloudas N, Pang J, Koktzoglou I
J Cardiovasc Magn Reson: 31 Oct 2021; 23:127 | PMID: 34724939
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Abstract

Non-transmural myocardial infarction associated with regional contractile function is an independent predictor of positive outcome: an integrated approach to myocardial viability.

Di Bella G, Aquaro GD, Bogaert J, Piaggi P, ... Khandheria BK, Pingitore A
Background
Cardiovascular magnetic resonance permits assessment of irreversible myocardial fibrosis and contractile function in patients with previous myocardial infarction. We aimed to assess the prognostic value of myocardial fibrotic tissue with preserved/restored contractile activity.
Methods
In 730 consecutive myocardial infarction patients (64 ± 11 years), we quantified left ventricular (LV) end-diastolic (EDV) and end-systolic (ESV) volumes, ejection fraction (EF), regional wall motion (WM) (1 normal, 2 hypokinetic, 3 akinetic, 4 dyskinetic), and WM score index (WMSI), and measured the transmural (1-50 and 51-100) and global extent of the infarct scar by late gadolinium enhancement (LGE). Contractile fibrotic (CT-F) segments were identified as those showing WM-1 and WM-2 with LGE ≤ or ≥ 50%.
Results
During follow-up (median 2.5, range 1-4.7 years), cardiac events (cardiac death or appropriate implantable defibrillator shocks) occurred in 123 patients (17%). At univariate analysis, age, LVEDV, LVESV, LVEF, WMSI, extent of LGE, segments with transmural extent > 50%, and CT-F segments were associated with cardiac events. At multivariate analysis, age > 65 years, LVEF < 30%, WMSI > 1.7, and dilated LVEDV independently predicted cardiac events, while CT-F tissue was the only independent predictor of better outcome. After adjustment for LVEF < 30% and LVEDV dilatation, the presence of CT-F tissue was associated with good prognosis.
Conclusions
In addition to CMR imaging parameters associated with adverse outcome (severe LV dysfunction, poor WM, and dilated EDV), the presence of fibrotic myocardium showing contractile activity in patients with previous myocardial infarction yields a beneficial effect on patient survival.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 31 Oct 2021; 23:121
Di Bella G, Aquaro GD, Bogaert J, Piaggi P, ... Khandheria BK, Pingitore A
J Cardiovasc Magn Reson: 31 Oct 2021; 23:121 | PMID: 34719402
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Abstract

Half-Dose Direct Oral Anticoagulation Versus Standard Antithrombotic Therapy After Left Atrial Appendage Occlusion.

Della Rocca DG, Magnocavallo M, Di Biase L, Mohanty S, ... Gibson DN, Natale A
Objectives
This study evaluated the long-term efficacy of a standard antithrombotic strategy versus half-dose direct oral anticoagulation (DOAC) after Watchman implantation.
Background
No consensus currently exists on the selection of the most effective antithrombotic strategy to prevent device-related thrombosis (DRT) in patients undergoing endocardial left atrial appendage closure.
Methods
After successful left atrial appendage closure, consecutive patients were prescribed a standard antithrombotic strategy (SAT) or long-term half-dose DOAC (hdDOAC). The primary composite endpoint was DRT and thromboembolic (TE) and bleeding events.
Results
Overall, 555 patients (mean age 75 ± 8 years, 63% male; median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category] score 4 [interquartile range (IQR): 3-6]; median HAS-BLED [hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol] score 3 [IQR: 2-4]) were included. Patients were categorized into 2 groups (SAT: n = 357 vs hdDOAC: n = 198). Baseline clinical characteristics were similar between groups. The median follow-up duration was 13 months (IQR: 12-15 months). DRT occurred in 12 (2.1%) patients, all in the SAT group (3.4% vs 0.0%; log-rank P = 0.009). The risk of nonprocedural major bleeding was significantly more favorable in the hdDOAC group (0.5% vs. 3.9%; log-rank P = 0.018). The rate of the primary composite endpoint of DRT and TE and major bleeding events was 9.5% in SAT patients and 1.0% in hdDOAC patients (HR: 9.8; 95% CI: 2.3-40.7; P = 0.002).
Conclusions
After successful Watchman implantation, long-term half-dose DOAC significantly reduced the risk of the composite endpoint of DRT and TE and major bleeding events compared with a standard, antiplatelet-based, antithrombotic therapy.

Copyright © 2021. Published by Elsevier Inc.

JACC Cardiovasc Interv: 07 Nov 2021; 14:2353-2364
Della Rocca DG, Magnocavallo M, Di Biase L, Mohanty S, ... Gibson DN, Natale A
JACC Cardiovasc Interv: 07 Nov 2021; 14:2353-2364 | PMID: 34656496
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Abstract

Association of baseline and change in global longitudinal strain by computed tomography with post-transcatheter aortic valve replacement outcomes.

Fukui M, Hashimoto G, Lopes BBC, Stanberry LI, ... Lesser JR, Cavalcante JL
Aims
Transcatheter aortic valve replacement (TAVR) procedural planning requires computed tomography angiography (CTA) which allows for the assessment of left ventricular global longitudinal strain (CTA-LVGLS). There is, however, limited data on the feasibility of CTA-LVGLS, and its prognostic value. This study sought to evaluate the incremental prognostic value of baseline CTA-LVGLS, change in CTA-LVGLS after TAVR, and their association with post-TAVR outcomes.
Methods and results
A total of 431 patients who underwent multiphasic gated CTA using dual-source system for TAVR planning at baseline and 1-month follow-up were included [median (interquartile range) age, 83 (77-87) years; 44% female, STS-PROM score: 3.3 (2.3-5.1)%, Echo-left ventricular ejection fraction (LVEF): 60 (55-65)%, CTA-LVGLS: -18.0 (-21.6 to -14.2)%, feasible in 97% of patients]. CTA-LVGLS was measured using dedicated feature-tracking software. Over a median follow-up of 19 (13-27) months, 99 endpoints of all-cause death or heart failure hospitalization occurred. The relative hazard of the endpoint increased as baseline CTA-LVGLS worsened with -18.2% as the threshold for higher events (P = 0.005). After adjustment for baseline characteristics, CTA-LVGLS remained associated with the endpoint [hazard ratio (HR) (95% confidence interval, CI), 1.08 (1.03-1.14); P = 0.005] and incrementally improved prognostication (C-index difference, 0.026). Although CTA-LVGLS improved after TAVR [-18.3 (-21.6 to -14.3)% vs. -18.7 (-21.9 to -15.4)%, P < 0.001], patients without CTA-LVGLS improvement had higher risk of the endpoint than those with improvement or preserved baseline global longitudinal strain [HR (95% CI), 1.92 (1.19-3.12); P = 0.008].
Conclusions
In this predominantly low-risk TAVR cohort of patients, mostly with normal LVEF, assessment of CTA-LVGLS is highly feasible improving risk stratification by providing independent and incremental prognostic value over clinical and echocardiographic characteristics.

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: 12 Nov 2021; epub ahead of print
Fukui M, Hashimoto G, Lopes BBC, Stanberry LI, ... Lesser JR, Cavalcante JL
Eur Heart J Cardiovasc Imaging: 12 Nov 2021; epub ahead of print | PMID: 34791101
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Abstract

Adverse fibrosis remodeling and aortopulmonary collateral flow are associated with poor Fontan outcomes.

Pisesky A, Reichert MJE, de Lange C, Seed M, ... Lam CZ, Grosse-Wortmann L
Background
The extent and significance in of cardiac remodeling in Fontan patients are unclear and were the subject of this study.
Methods
This retrospective cohort study compared cardiovascular magnetic resonance (CMR) imaging markers of cardiac function, myocardial fibrosis, and hemodynamics in young Fontan patients to controls.
Results
Fifty-five Fontan patients and 44 healthy controls were included (median age 14 years (range 7-17 years) vs 13 years (range 4-14 years), p = 0.057). Fontan patients had a higher indexed end-diastolic ventricular volume (EDVI 129 ml/m2 vs 93 ml/m2, p < 0.001), and lower ejection fraction (EF 45% vs 58%, p < 0.001), circumferential (CS - 23.5% vs - 30.8%, p < 0.001), radial (6.4% vs 8.2%, p < 0.001), and longitudinal strain (- 13.3% vs - 24.8%, p < 0.001). Compared to healthy controls, Fontan patients had higher extracellular volume fraction (ECV) (26.3% vs 20.6%, p < 0.001) and native T1 (1041 ms vs 986 ms, p < 0.001). Patients with a dominant right ventricle demonstrated larger ventricles (EDVI 146 ml/m2 vs 120 ml/m2, p = 0.03), lower EF (41% vs 47%, p = 0.008), worse CS (- 20.1% vs - 25.6%, p = 0.003), and a trend towards higher ECV (28.3% versus 24.1%, p = 0.09). Worse EF and CS correlated with longer cumulative bypass (R = - 0.36, p = 0.003 and R = 0.46, p < 0.001), cross-clamp (R = - 0.41, p = 0.001 and R = 0.40, p = 0.003) and circulatory arrest times (R = - 0.42, p < 0.001 and R = 0.27, p = 0.03). T1 correlated with aortopulmonary collateral (APC) flow (R = 0.36, p = 0.009) which, in the linear regression model, was independent of ventricular morphology (p = 0.9) and EDVI (p = 0.2). The composite outcome (cardiac readmission, cardiac reintervention, Fontan failure or any clinically significant arrhythmia) was associated with increased native T1 (1063 ms vs 1026 ms, p = 0.029) and EDVI (146 ml/m2 vs 118 ml/m2, p = 0.013), as well as decreased EF (42% vs 46%, p = 0.045) and worse CS (- 22% vs - 25%, p = 0.029). APC flow (HR 5.5 CI 1.9-16.2, p = 0.002) was independently associated with the composite outcome, independent of ventricular morphology (HR 0.71 CI 0.30-1.69 p = 0.44) and T1 (HR1.006 CI 1.0-1.13, p = 0.07).
Conclusions
Pediatric Fontan patients have ventricular dysfunction, altered myocardial mechanics and increased fibrotic remodeling. Cumulative exposure to cardiopulmonary bypass and increased aortopulmonary collateral flow are associated with myocardial dysfunction and fibrosis. Cardiac dysfunction, fibrosis, and collateral flow are associated with adverse outcomes.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 14 Nov 2021; 23:134
Pisesky A, Reichert MJE, de Lange C, Seed M, ... Lam CZ, Grosse-Wortmann L
J Cardiovasc Magn Reson: 14 Nov 2021; 23:134 | PMID: 34781968
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Abstract

Prognostic Implications of Progressive Systemic Ventricular Dysfunction in Congenitally Corrected Transposition of Great Arteries.

Egbe AC, Miranda WR, Jain CC, Connolly HM
Objectives
The purpose of this study was to determine the risk factors for and prognostic implications of progressive right ventricular systolic dysfunction (RVD) in adults with congenitally corrected transposition of great arteries.
Background
There are no effective therapies for RVD; hence the need to identify and modify risk factors for progressive RVD.
Methods
RV systolic function was assessed by using RV longitudinal strain (RV-LS). The first echocardiogram (baseline echocardiogram) and all subsequent annual echocardiograms performed within 5 years from the baseline echocardiogram were analyzed. Progressive RVD (temporal decline in RV-LS) was assessed as the average annual change in RV-LS within 5 years of imaging follow-up.
Results
Of 186 patients (mean age 40 ± 12 years), the RV-LS at baseline was -17% ± 4%, and the annual decline in RV-LS was -4% (95% CI: -6 to -2). The risk factors for progressive RVD were left ventricular (LV) systolic dysfunction, LV pacing, and systemic hypertension. Cardiovascular events (heart failure hospitalization, heart transplant, and death) occurred in 57 (27%) patients. Progressive RVD was associated with cardiovascular events, independent of RV systolic function at baseline. In subgroup analyses assessing impact of therapies (medical therapy, cardiac resynchronization therapy, and tricuspid valve replacement), only tricuspid valve replacement was associated with improvement in RV systolic function when performed before onset of RVD.
Conclusions
Patients with congenitally corrected transposition of great arteries were at risk for progressive RVD, and the risk factors for progressive RVD were LV pacing, systemic hypertension, and concomitant LV dysfunction. Further studies are required to determine whether strict blood pressure control and early tricuspid valve replacement will prevent progressive RVD.

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

JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print
Egbe AC, Miranda WR, Jain CC, Connolly HM
JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print | PMID: 34801447
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Impact:
Abstract

Biomarkers of Vascular Inflammation for Cardiovascular Risk Prognostication: A Meta-Analysis.

Antonopoulos AS, Angelopoulos A, Papanikolaou P, Simantiris S, ... Antoniades C, Tousoulis D
Background
Measurement of biomarkers of vascular inflammation is advocated for the risk stratification for coronary heart disease (CHD).
Objectives
To systematically explore the added value of biomarkers of vascular inflammation for cardiovascular prognostication on top of clinical risk factors.
Methods
We systematically explored published reports in MEDLINE for cohort studies on the prognostic value of common biomarkers of vascular inflammation in stable patients without known CHD. These included common circulating inflammatory biomarkers (ie, C-reactive protein, interleukin-6 and tumor necrosis factor-a, arterial positron emission tomography/computed tomography and coronary computed tomography angiography-derived biomarkers of vascular inflammation, including anatomical high-risk plaque features and perivascular fat imaging. The main endpoint was the difference in c-index (Δ[c-index]) with the use of inflammatory biomarkers for major adverse cardiovascular events (MACEs) and mortality. We calculated I2 to test heterogeneity. This study is registered with PROSPERO (CRD42020181158).
Results
A total of 104,826 relevant studies were screened and a final of 39 independent studies (175,778 individuals) were included in the quantitative synthesis. Biomarkers of vascular inflammation provided added prognostic value for the composite endpoint and for MACEs only (pooled estimate for Δ[c-index]% 2.9, 95% CI: 1.7-4.1 and 3.1, 95% CI: 1.8-4.5, respectively). Coronary computed tomography angiography-related biomarkers were associated with the highest added prognostic value for MACEs: high-risk plaques 5.8%, 95% CI: 0.6 to 11.0, and perivascular adipose tissue (on top of coronary atherosclerosis extent and high-risk plaques): 8.2%, 95% CI: 4.0 to 12.5). In meta-regression analysis, the prognostic value of inflammatory biomarkers was independent of other confounders including study size, length of follow-up, population event incidence, the performance of the baseline model, and the level of statistical adjustment. Limitations in the published literature include the lack of reporting of other metrics of improvement of risk stratification, the net clinical benefit, or the cost-effectiveness of such biomarkers in clinical practice.
Conclusions
The use of biomarkers of vascular inflammation enhances risk discrimination for cardiovascular events.

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

JACC Cardiovasc Imaging: 08 Nov 2021; epub ahead of print
Antonopoulos AS, Angelopoulos A, Papanikolaou P, Simantiris S, ... Antoniades C, Tousoulis D
JACC Cardiovasc Imaging: 08 Nov 2021; epub ahead of print | PMID: 34801448
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Impact:
Abstract

Combined Coronary CT-Angiography and TAVR Planning for Ruling Out Significant Coronary Artery Disease: Added Value of Machine-Learning-Based CT-FFR.

Gohmann RF, Pawelka K, Seitz P, Majunke N, ... Abdel-Wahab M, Gutberlet M
Objectives
To analyze the ability of machine-learning (ML)-based computed tomography (CT)-derived fractional flow reserve (CT-FFR) to further improve the diagnostic performance of coronary CT angiography (cCTA) for ruling out significant coronary artery disease (CAD) during pre-transcatheter aortic valve replacement (TAVR) evaluation in patients with a high pre-test probability for CAD.
Background
CAD is a frequent comorbidity in patients undergoing TAVR. Current guidelines recommend its assessment before TAVR. If significant CAD can be excluded on cCTA, invasive coronary angiography (ICA) may be avoided. Although cCTA is a very sensitive test, it is limited by relatively low specificity and positive predictive value, particularly in high-risk patients.
Methods
Overall, 460 patients (79.6 ± 7.4 years) undergoing pre-TAVR CT were included and examined with an electrocardiogram-gated CT scan of the heart and high-pitch scan of the vascular access route. Images were evaluated for significant CAD. Patients routinely underwent ICA (388/460), which was omitted at the discretion of the local Heart Team if CAD could be effectively ruled out on cCTA (72/460). CT examinations in which CAD could not be ruled out (CAD+) (n = 272) underwent additional ML-based CT-FFR.
Results
ML-based CT-FFR was successfully performed in 79.4% (216/272) of all CAD+ patients and correctly reclassified 17 patients as CAD negative. CT-FFR was not feasible in 20.6% because of reduced image quality (37/56) or anatomic variants (19/56). Sensitivity, specificity, positive predictive value, and negative predictive value were 94.9%, 52.0%, 52.2%, and 94.9%, respectively. The additional evaluation with ML-based CT-FFR increased accuracy by Δ+3.4% (CAD+: Δ+6.0%) and raised the total number of examinations negative for CAD to 43.9% (202/460).
Conclusions
ML-based CT-FFR may further improve the diagnostic performance of cCTA by correctly reclassifying a considerable proportion of patients with morphological signs of obstructive CAD on cCTA during pre-TAVR evaluation. Thereby, CT-FFR has the potential to further reduce the need for ICA in this challenging elderly group of patients before TAVR.

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

JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print
Gohmann RF, Pawelka K, Seitz P, Majunke N, ... Abdel-Wahab M, Gutberlet M
JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print | PMID: 34801449
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Abstract

Mean Versus Peak Coronary Calcium Density on Non-Contrast CT: Calcium Scoring and ASCVD Risk Prediction.

Dzaye O, Razavi AC, Dardari ZA, Berman DS, ... Whelton SP, Blaha MJ
Objectives
This study sought to assess the relationship between mean vs peak calcified plaque density and their impact on calculating coronary artery calcium (CAC) scores and to compare the corresponding differential prediction of atherosclerotic cardiovascular disease (ASCVD) and coronary heart disease (CHD) mortality.
Background
The Agatston CAC score is quantified per lesion as the product of plaque area and a 4-level categorical peak calcium density factor. However, mean calcium density may more accurately measure the heterogenous mixture of lipid-rich, fibrous, and calcified plaque reflective of ASCVD risk.
Methods
We included 10,373 individuals from the CAC Consortium who had CAC >0 and per-vessel measurements of peak calcium density factor and mean calcium density. Area under the curve and continuous net reclassification improvement analyses were performed for CHD and ASCVD mortality to compare the predictive abilities of mean calcium density vs peak calcium density factor when calculating the Agatston CAC score.
Results
Participants were on average 53.4 years of age, 24.4% were women, and the median CAC score was 68 Agatston units. The average values for mean calcium density and peak calcium density factor were 210 ± 50 Hounsfield units and 3.1 ± 0.5, respectively. Individuals younger than 50 years of age and/or those with a total plaque area <100 mm2 had the largest differences between the peak and mean density measures. Among persons with CAC 1-99, the use of mean calcium density resulted in a larger improvement in ASCVD mortality net reclassification improvement (NRI) (NRI = 0.49; P < 0.001 vs. NRI = 0.18; P = 0.08) and CHD mortality discrimination (Δ area under the curve (AUC) = +0.169 vs +0.036; P < 0.001) compared with peak calcium density factor. Neither peak nor mean calcium density improved mortality prediction at CAC scores >100.
Conclusion
Mean and peak calcium density may differentially describe plaque composition early in the atherosclerotic process. Mean calcium density performs better than peak calcium density factor when combined with plaque area for ASCVD mortality prediction among persons with Agatston CAC 1-99.

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

JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print
Dzaye O, Razavi AC, Dardari ZA, Berman DS, ... Whelton SP, Blaha MJ
JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print | PMID: 34801452
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Abstract

Automated Analysis of Doppler Echocardiographic Videos as a Screening Tool for Valvular Heart Diseases.

Yang F, Chen X, Lin X, Chen X, ... Wang Q, He K
Objectives
This study sought to develop a deep learning (DL) framework to automatically analyze echocardiographic videos for the presence of valvular heart diseases (VHDs).
Background
Although advances in DL have been applied to the interpretation of echocardiograms, such techniques have not been reported for interpretation of color Doppler videos for diagnosing VHDs.
Methods
We developed a 3-stage DL framework for automatic screening of echocardiographic videos for mitral stenosis (MS), mitral regurgitation (MR), aortic stenosis (AS), and aortic regurgitation (AR) that classifies echocardiographic views, detects the presence of VHDs, and, when present, quantifies key metrics related to VHD severities. The algorithm was trained (n = 1,335), validated (n = 311), and tested (n = 434) using retrospectively selected studies from 5 hospitals. A prospectively collected set of 1,374 consecutive echocardiograms served as a real-world test data set.
Results
Disease classification accuracy was high, with areas under the curve of 0.99 (95% CI: 0.97-0.99) for MS; 0.88 [95% CI: 0.86-0.90] for MR; 0.97 [95% CI: 0.95-0.99] for AS; and 0.90 [95% CI: 0.88-0.92]) for AR in the prospective test data set. The limits of agreement (LOA) between the DL algorithm and physician estimates of metrics of valve lesion severities compared to the LOAs between 2 experienced physicians spanned from -0.60 to 0.77 cm2 vs -0.48 to 0.44 cm2 for MV area; from -0.27 to 0.25 vs -0.23 to 0.08 for MR jet area/left atrial area; from -0.86 to 0.52 m/s vs -0.48 to 0.54 m/s for peak aortic valve blood flow velocity (Vmax); from -10.6 to 9.5 mm Hg vs -10.2 to 4.9 mm Hg for average peak aortic valve gradient; and from -0.39 to 0.32 vs -0.31 to 0.32 for AR jet width/left ventricular outflow tract diameter.
Conclusions
The proposed deep learning algorithm has the potential to automate and increase efficiency of the clinical workflow for screening echocardiographic images for the presence of VHDs and for quantifying metrics of disease severity.

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

JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print
Yang F, Chen X, Lin X, Chen X, ... Wang Q, He K
JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print | PMID: 34801459
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Abstract

Subclinical Pulmonary Congestion and Abnormal Hemodynamics in Heart Failure With Preserved Ejection Fraction.

Jain CC, Tschirren J, Reddy YNV, Melenovsky V, Redfield M, Borlaug BA
Objectives
We hypothesized that quantitative computed tomography (QCT) imaging would reveal subclinical increases in lung congestion in patients with heart failure and preserved ejection fraction (HFpEF) and that this would be related to pulmonary vascular hemodynamic abnormalities.
Background
Gross evidence of lung congestion on physical examination, laboratory tests, and radiography is typically absent among compensated ambulatory patients with HFpEF. However, pulmonary gas transfer abnormalities are commonly observed and associated with poor outcomes.
Methods
Patients referred for invasive hemodynamic exercise testing who had undergone chest computed tomography imaging within 1 month were identified (N = 137). A novel artificial intelligence QCT algorithm was used to measure pulmonary fluid content.
Results
Compared with control subjects with noncardiac dyspnea, patients with HFpEF displayed increased mean lung density (-758 Hounsfield units [HU] [-793, -709 HU] Hounsfield units vs -787 HU [-828, -747 HU]; P = 0.002) and a higher ratio of extravascular lung water to total lung volume (EVLWV/TLV) (1.25 [0.80, 1.76] vs 0.66 [0.01, 1.03]; P < 0.0001) by QCT imaging, indicating greater lung congestion. EVLWV/TLV was directly correlated with pulmonary vascular pressures at rest, with stronger correlations observed during exercise. Patients with increasing tertiles of EVLWV/TLV demonstrated higher mean pulmonary artery pressures at rest (34 ± 11 mm Hg vs 39 ± 14 mm Hg vs 45 ± 17 mm Hg; P = 0.0003) and during exercise (55 ± 17 mm Hg vs 59 ± 17 mm Hg vs 69 ± 22 mm Hg; P = 0.0003).
Conclusions
QCT imaging identifies subclinical lung congestion in HFpEF that is not clinically apparent but is related to abnormalities in pulmonary vascular hemodynamics. These data provide new insight into the long-term effects of altered hemodynamics on pulmonary structure and function in HFpEF.

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

JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print
Jain CC, Tschirren J, Reddy YNV, Melenovsky V, Redfield M, Borlaug BA
JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print | PMID: 34801461
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Abstract

The REPAIR Study: Effects of Macitentan on RV Structure and Function in Pulmonary Arterial Hypertension.

Vonk Noordegraaf A, Channick R, Cottreel E, Kiely DG, ... Rosenkranz S, Galiè N
Objectives
The REPAIR (Right vEntricular remodeling in Pulmonary ArterIal hypeRtension) study evaluated the effect of macitentan on right ventricular (RV) and hemodynamic outcomes in patients with pulmonary arterial hypertension (PAH), using cardiac magnetic resonance (CMR) and right heart catheterization (RHC).
Background
RV failure is the primary cause of death in PAH. CMR is regarded as the most accurate noninvasive method for assessing RV function and remodeling and CMR measures of RV function and structure are strongly prognostic for survival in patients with PAH. Despite this, CMR is not routinely used in PAH clinical trials.
Methods
REPAIR was a 52-week, open-label, single-arm, multicenter, phase 4 study evaluating the effect of macitentan 10 mg, with or without phosphodiesterase type-5 inhibition, on RV remodeling and function and cardiopulmonary hemodynamics. Primary endpoints were change from baseline to week 26 in RV stroke volume, determined by CMR; and pulmonary vascular resistance, determined by RHC. Efficacy measures were assessed for all patients with baseline and week 26 data for both primary endpoints.
Results
At a prespecified interim analysis in 42 patients, both primary endpoints were met, enrollment was stopped, and the study was declared positive. At final analysis (n = 71), RV stroke volume increased by 12 mL (96% confidence level: 8.4-15.6 mL; P < 0.0001) and pulmonary vascular resistance decreased by 38% (99% confidence level: 31%-44%; P < 0.0001) at week 26. Significant positive changes were also observed in secondary and exploratory CMR (RV and left ventricular), hemodynamic, and functional endpoints at week 26. Improvements in CMR RV and left ventricular variables and functional parameters were maintained at week 52. Safety (n = 87) was consistent with previous clinical trials.
Conclusions
In the context of this study, macitentan treatment in patients with PAH resulted in significant and clinically-relevant improvements in RV function and structure and cardiopulmonary hemodynamics. At 52 weeks, improvements in RV function and structure were sustained. (REPAIR: Right vEntricular remodeling in Pulmonary ArterIal hypeRtension [REPAIR]; NCT02310672).

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

JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print
Vonk Noordegraaf A, Channick R, Cottreel E, Kiely DG, ... Rosenkranz S, Galiè N
JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print | PMID: 34801462
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Abstract

Wall Shear Stress Predicts Aortic Dilation in Patients With Bicuspid Aortic Valve.

Guala A, Dux-Santoy L, Teixido-Tura G, Ruiz-Muñoz A, ... Evangelista A, Rodríguez-Palomares JF
Objectives
This study sought to assess the predictive value of wall shear stress (WSS) for colocalized ascending aorta (AAo) growth rate (GR) in patients with bicuspid aortic valve (BAV).
Background
BAV is associated with AAo dilation, but there is limited knowledge about possible predictors of aortic dilation in BAV patients with BAV. An increased WSS has been related to aortic wall damage in patients with BAV, but no previous prospective study tested its predictive value for dilation rate. Recently, a registration-based technique for the semiautomatic mapping of aortic GR has been presented and validated.
Methods
Forty-seven patients with BAV free from valvular dysfunction prospectively underwent 4-dimensional flow cardiac magnetic resonance to compute WSS and subsequent follow-up with 2 electrocardiogram-gated high-resolution contrast-enhanced computed tomography angiograms for GR assessment.
Results
During a median follow-up duration of 43 months, mid AAo GR was 0.24 mm/year. WSS and its circumferential component showed statistically significant association with mid AAo GR in bivariate (P = 0.049 and P = 0.014, respectively) and in multivariate analysis corrected for stroke volume and either baseline AAo diameter (P = 0.046 and P = 0.014, respectively) or z-score (P = 0.036 and P = 0.012, respectively). GR mapping further detailed that GR was heterogeneous in the AAo and that circumferential WSS, but not WSS magnitude, showed statistically significant positive associations with GR in the regions with the fastest growth.
Conclusions
4D flow cardiac magnetic resonance-derived WSS and, in particular, its circumferential component predict progressive dilation of the ascending aorta in patients with BAV. Thus, the assessment of WSS may be considered in the follow-up of these patients.

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

JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print
Guala A, Dux-Santoy L, Teixido-Tura G, Ruiz-Muñoz A, ... Evangelista A, Rodríguez-Palomares JF
JACC Cardiovasc Imaging: 05 Nov 2021; epub ahead of print | PMID: 34801463
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Abstract

Left atrial appendage closure for thrombus trapping: the international, multicentre TRAPEUR registry.

Sebag FA, Garot P, Galea R, De Backer O, ... Räber L, Amabile N
Background
Although the presence of a thrombus contraindicates left atrial appendage closure procedure (LAAC), a previous study reported the feasibility of the thrombus trapping procedure (TTP) technique to overcome this limitation.
Aims
This study aimed to analyse the short-term outcomes in a series of patients who underwent LAAC using the TTP (TTP-LAAC).
Methods
This retrospective series included patients who underwent TTP-LAAC between January 2018 and May 2020 in 13 European centres. Device choice, pre-interventional work-up and post-discharge antithrombotic therapy regimens were left to the discretion of the operators. The primary endpoint was the 30-day occurrence of stroke, systemic embolism or cardiovascular death.
Results
During the study period, a total of 1,918 patients underwent LAAC. A thrombus was identified in 71 cases but completely disappeared in 24 patients before procedure. TTP-LAAC was finally performed in 53 cases (3%). Thrombi were identified ahead of the actual day of implantation in 47 patients (87 %) and were mostly limited in size (50 cases with extension &lt;50% LAA surface). The Amplatzer Amulet and WATCHMAN FLX occluders were implanted in 44 and 9 patients, respectively. A single deployment approach was applied in 70% and a cerebral embolic protection system was used in 9% of the patients. The overall success rate was 100%. Small pericardial effusion without tamponade was observed in 6% of the cases. Patients were discharged with 72% under antiplatelet therapy and 10% under short-term oral anticoagulation. The primary endpoint occurred in one patient.
Conclusions
TTP-LAAC might be used in a minority of LAAC procedures but appears to be feasible and safe in the short-term, in select cases.



EuroIntervention: 17 Nov 2021; epub ahead of print
Sebag FA, Garot P, Galea R, De Backer O, ... Räber L, Amabile N
EuroIntervention: 17 Nov 2021; epub ahead of print | PMID: 34794937
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Abstract

Multi-parametric cardiovascular magnetic resonance with regadenoson stress perfusion is safe following pediatric heart transplantation and identifies history of rejection and cardiac allograft vasculopathy.

Husain N, Watanabe K, Berhane H, Gupta A, ... Rigsby CK, Robinson JD
Background
The progressive risk of graft failure in pediatric heart transplantation (PHT) necessitates close surveillance for rejection and coronary allograft vasculopathy (CAV). The current gold standard of surveillance via invasive coronary angiography is costly, imperfect and associated with complications. Our goal was to assess the safety and feasibility of a comprehensive multi-parametric CMR protocol with regadenoson stress perfusion in PHT and evaluate for associations with clinical history of rejection and CAV.
Methods
We performed a retrospective review of 26 PHT recipients who underwent stress CMR with tissue characterization and compared with 18 age-matched healthy controls. CMR protocol included myocardial T2, T1 and extracellular volume (ECV) mapping, late gadolinium enhancement (LGE), qualitative and semi-quantitative stress perfusion (myocardial perfusion reserve index; MPRI) and strain imaging. Clinical, demographics, rejection score and CAV history were recorded and correlated with CMR parameters.
Results
Mean age at transplant was 9.3 ± 5.5 years and median duration since transplant was 5.1 years (IQR 7.5 years). One patient had active rejection at the time of CMR, 11/26 (42%) had CAV 1 and 1/26 (4%) had CAV 2. Biventricular volumes were smaller and cardiac output higher in PHT vs. healthy controls. Global T1 (1053 ± 42 ms vs 986 ± 42 ms; p < 0.001) and ECV (26.5 ± 4.0% vs 24.0 ± 2.7%; p = 0.017) were higher in PHT compared to helathy controls. Significant relationships between changes in myocardial tissue structure and function were noted in PHT: increased T2 correlated with reduced LVEF (r = - 0.57, p = 0.005), reduced global circumferential strain (r = - 0.73, p < 0.001) and reduced global longitudinal strain (r = - 0.49, p = 0.03). In addition, significant relationships were noted between higher rejection score and global T1 (r = 0.38, p = 0.05), T2 (r = 0.39, p = 0.058) and ECV (r = 0.68, p < 0.001). The presence of even low-grade CAV was associated with higher global T1, global ECV and maximum segmental T2. No major side effects were noted with stress testing. MPRI was analyzed with good interobserver reliability and was lower in PHT compared to healthy controls (0.69 ± - 0.21 vs 0.94 ± 0.22; p < 0.001).
Conclusion
In a PHT population with low incidence of rejection or high-grade CAV, CMR demonstrates important differences in myocardial structure, function and perfusion compared to age-matched healthy controls. Regadenoson stress perfusion CMR could be safely and reliably performed. Increasing T2 values were associated with worsening left ventricular function and increasing T1/ECV values were associated with rejection history and low-grade CAV. These findings warrant larger prospective studies to further define the role of CMR in PHT graft surveillance.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 21 Nov 2021; 23:135
Husain N, Watanabe K, Berhane H, Gupta A, ... Rigsby CK, Robinson JD
J Cardiovasc Magn Reson: 21 Nov 2021; 23:135 | PMID: 34809650
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Impact:

This program is still in alpha version.