<div><h4>Effect of etelcalcetide versus alfacalcidol on left ventricular function and feature-tracking cardiac magnetic resonance imaging in hemodialysis-a post-hoc analysis of a randomized, controlled trial.</h4><i>Dörr K, Kammerlander A, Lauriero F, Lorenz M, Marculescu R, Beitzke D</i><br /><b>Background</b><br />Calcimimetic therapy with etelcalcetide (ETEL) has been shown to attenuate the advancement of left ventricular (LV) hypertrophy in hemodialysis patients measured by cardiac magnetic resonance (CMR). The aim of the study was to evaluate whether this effect is accompanied by alterations in LV function and myocardial composition.<br /><b>Methods</b><br />This was a post-hoc analysis of a randomized-controlled trial of ETEL versus Alfacalcidol (ALFA) in 62 hemodialysis patients. LV function was assessed using LV ejection fraction (LVEF) and LV global longitudinal strain (GLS) on feature-tracking (FT) CMR. Myocardial tissue characteristics were analyzed using parametric T1 and T2 mapping.<br /><b>Results</b><br />Of the total study cohort (n = 62), 48 subjects completed both CMR scans with sufficient quality for FT analysis. In the one-year follow-up, LV GLS deteriorated in the ALFA group, whereas the ETEL group remained stable (LV GLS change: + 2.6 ± 4.6 versus + 0.3 ± 3.8; p = 0.045 when adjusting for randomization factors and baseline LV GLS). We did not observe a difference in the change of LVEF between the two groups (p = 0.513). The impact of ETEL treatment on LV GLS over time remained significant after additional adjustment for the change in LV mass during the study period. ETEL treatment did not significantly affect other CMR parameters. There were no changes in myocardial composition between treatment groups (T1 time change: + 15 ± 42 versus + 10 ± 50; p = 0.411; T2 time change: - 0.13 ± 2.45 versus - 0.70 ± 2.43; p = 0.652).<br /><b>Conclusions</b><br />In patients undergoing hemodialysis, treatment with ETEL was protective against deterioration of LV longitudinal function, as evaluated through FT CMR, when compared to the control therapy of ALFA. This effect was not mediated by the change in LV mass. Trial registration URL: https://clinicaltrials.gov/ct2/show/NCT03182699 . Unique identifier: NCT03182699.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 06 Nov 2023; 25:62</small></div>

<div><h4>Late-gadolinium enhancement is common in older pediatric heart transplant recipients and is associated with lower ejection fraction.</h4><i>Lawson AA, Watanabe K, Griffin L, Laternser C, ... Robinson JD, Husain N</i><br /><b>Background</b><br />Chronic graft failure and cumulative rejection history in pediatric heart transplant recipients (PHTR) are associated with myocardial fibrosis on endomyocardial biopsy (EMB). Cardiovascular magnetic resonance imaging (CMR) is a validated, non-invasive method to detect myocardial fibrosis via the presence of late gadolinium enhancement (LGE). In adult heart transplant recipients, LGE is associated with increased risk of future adverse clinical events including hospitalization and death. We describe the prevalence, pattern, and extent of LGE on CMR in a cohort of PHTR and its associations with recipient and graft characteristics.<br /><b>Methods</b><br />This was a retrospective study of consecutive PHTR who underwent CMR over a 6-year period at a single center. Two independent reviewers assessed the presence and distribution of left ventricular (LV) LGE using the American Heart Association (AHA) 17-segment model. LGE quantification was performed on studies with visible fibrosis (LGE+). Patient demographics, clinical history, and CMR-derived volumetry and ejection fractions were obtained.<br /><b>Results</b><br />Eighty-one CMR studies were performed on 59 unique PHTR. Mean age at CMR was 14.8 ± 6.2 years; mean time since transplant was 7.3 ± 5.0 years. The CMR indication was routine surveillance (without a clinical concern based on laboratory parameters, echocardiography, or cardiac catheterization) in 63% (51/81) of studies. LGE was present in 36% (29/81) of PHTR. In these LGE + studies, patterns included inferoseptal in 76% of LGE + studies (22/29), lateral wall in 41% (12/29), and diffuse, involving > 4 AHA segments, in 21% (6/29). The mean LV LGE burden as a percentage of myocardial mass was 18.0 ± 9.0%. When reviewing only the initial CMR per PHTR (n = 59), LGE + patients were older (16.7 ± 2.9 vs. 12.8 ± 4.6 years, p = 0.001), with greater time since transplant (8.3 ± 5.4 vs. 5.7 ± 3.9 years, p = 0.041). These patients demonstrated higher LV end-systolic volume index (LVESVI) (34.7 ± 11.7 vs. 28.7 ± 6.1 ml/m<sup>2</sup>, p = 0.011) and decreased LV ejection fraction (LVEF) (56.2 ± 8.1 vs. 60.6 ± 5.3%, p = 0.015). There were no significant differences in history of moderate/severe rejection (p = 0.196) or cardiac allograft vasculopathy (CAV) (p = 0.709).<br /><b>Conclusions</b><br />LV LGE was present in approximately one third of PHTR, more commonly in older patients with longer time since transplantation. Grafts with LGE have lower LVEF. CMR-derived LGE may aid in surveillance of chronic graft failure in PHTR.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 06 Nov 2023; 25:61</small></div>

<div><h4>Impact of temporal and spatial resolution on atrial feature tracking cardiovascular magnetic resonance imaging.</h4><i>Schmidt-Rimpler J, Backhaus SJ, Hartmann FP, Schaten P, ... Kelle S, Schuster A</i><br /><b>Background</b><br />Myocardial deformation assessment by cardiovascular magnetic resonance-feature tracking (CMR-FT) has incremental prognostic value over volumetric analyses. Recently, atrial functional analyses have come to the fore. However, to date recommendations for optimal resolution parameters for accurate atrial functional analyses are still lacking.<br /><b>Methods</b><br />CMR-FT was performed in 12 healthy volunteers and 9 ischemic heart failure (HF) patients. Cine sequences were acquired using different temporal (20, 30, 40 and 50 frames/cardiac cycle) and spatial resolution parameters (high 1.5 × 1.5 mm in plane and 5 mm slice thickness, standard 1.8 × 1.8 × 8 mm and low 3.0 × 3.0 × 10 mm). Inter- and intra-observer reproducibility were calculated.<br /><b>Results</b><br />Increasing temporal resolution is associated with higher absolute strain and strain rate (SR) values. Significant changes in strain assessment for left atrial (LA) total strain occurred between 20 and 30 frames/cycle amounting to 2,5-4,4% absolute changes depending on spatial resolution settings. From 30 frames/cycle onward, absolute strain values remained unchanged. Significant changes of LA strain rate assessment were observed up to the highest temporal resolution of 50 frames/cycle. Effects of spatial resolution on strain assessment were smaller. For LA total strain a general trend emerged for a mild decrease in strain values obtained comparing the lowest to the highest spatial resolution at temporal resolutions of 20, 40 and 50 frames/cycle (p = 0.006-0.046) but not at 30 frames/cycle (p = 0.140).<br /><b>Conclusion</b><br />Temporal and to a smaller extent spatial resolution affect atrial functional assessment. Consistent strain assessment requires a standard spatial resolution and a temporal resolution of 30 frames/cycle, whilst SR assessment requires even higher settings of at least 50 frames/cycle.<br /><br />Copyright © 2023 Elsevier Ireland Ltd. All rights reserved.<br /><br /><small>Int J Cardiol: 03 Nov 2023:131563; epub ahead of print</small></div>

<div><h4>State-of-the-Art Imaging of Infiltrative Cardiomyopathies: A Scientific Statement From the American Heart Association.</h4><i>Kottam A, Hanneman K, Schenone A, Daubert MA, ... Garcia MJ, American Heart Association Council on Cardiovascular Radiology and Intervention</i><br /><AbstractText>Infiltrative cardiomyopathies comprise a broad spectrum of inherited or acquired conditions caused by deposition of abnormal substances within the myocardium. Increased wall thickness, inflammation, microvascular dysfunction, and fibrosis are the common pathological processes that lead to abnormal myocardial filling, chamber dilation, and disruption of conduction system. Advanced disease presents as heart failure and cardiac arrhythmias conferring poor prognosis. Infiltrative cardiomyopathies are often diagnosed late or misclassified as other more common conditions, such as hypertrophic cardiomyopathy, hypertensive heart disease, ischemic or other forms of nonischemic cardiomyopathies. Accurate diagnosis is also critical because clinical features, testing methodologies, and approach to treatment vary significantly even within the different types of infiltrative cardiomyopathies on the basis of the type of substance deposited. Substantial advances in noninvasive cardiac imaging have enabled accurate and early diagnosis. thereby eliminating the need for endomyocardial biopsy in most cases. This scientific statement discusses the role of contemporary multimodality imaging of infiltrative cardiomyopathies, including echocardiography, nuclear and cardiac magnetic resonance imaging in the diagnosis, prognostication, and assessment of response to treatment.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Imaging: 02 Nov 2023:e000081; epub ahead of print</small></div>

<div><h4>Left bundle branch pacing better preserves ventricular mechanical synchrony than right ventricular pacing A two-center study.</h4><i>Mao Y, Duchenne J, Yang Y, Garweg C, ... Fu G, Voigt JU</i><br /><b>Aims</b><br />Left bundle branch pacing (LBBP) has been shown to better maintain electrical synchrony compared to right ventricular pacing (RVP), but little is known about its impact on mechanical synchrony. This study investigates if LBBP better preserves left ventricular (LV) mechanical synchronicity and function compared to RVP.<br /><b>Methods and results</b><br />Sixty patients with pacing indication for bradycardia were included: LBBP (n = 31) and RVP (n = 29). Echocardiography was performed before and shortly after pacemaker implantation and at one-year follow-up. The lateral-septal (LW-SW) work difference was used as a measure of mechanical dyssynchrony. Septal flash, apical rocking and septal strain patterns were also assessed. At baseline, LW-SW work difference was small and similar in two groups. SW was markedly decreased while LW work remained mostly unchanged in RVP, resulting in a larger LW-SW work difference compared to LBBP (1253 ± 687mmHg·% vs. 439 ± 408 mmHg·%, P < 0.01) at last follow-up. In addition, RVP more often induced septal flash or apical rocking, and resulted in more advanced strain patterns compared to LBBP. At one year follow-up, LV ejection fraction (EF) and global longitudinal strain (GLS) were more decreased in RVP compared to LBBP (ΔLVEF: -7.4 ± 7.0% vs 0.3 ± 4.1%; ΔLVGLS: -4.8 ± 4.0% vs -1.4 ± 2.5%, both P < 0.01). In addition, ΔLW-SW work difference was independently correlated with LV adverse remodeling (r = 0.42, P < 0.01) and LV dysfunction (ΔLVEF: r = -0.61, P < 0.01 and ΔLVGLS: r = -0.38, P = 0.02).<br /><b>Conclusion</b><br />LBBP causes less LV mechanical dyssynchrony than RVP as it preserves a more physiologic electrical conduction. As a consequence, LBBP appears to preserve LV function better than RVP.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 02 Nov 2023; epub ahead of print</small></div>

<div><h4>Left Atrial Strain in Acute Heart Failure: Clinical and Prognostic Insights.</h4><i>Barki M, Losito M, Caracciolo MM, Sugimoto T, ... Moroni A, Guazzi M</i><br /><b>Aims</b><br />In acute heart failure (AHF), the consequences of impaired left atrial (LA) mechanics are not well understood. We aimed to define the clinical trajectory of LA mechanics by left atrial strain (LAS) analysis.<br /><b>Methods and results</b><br />85 consecutive AHF patients with reduced, mildly reduced, and preserved left ventricular ejection fraction (LVEF) were enrolled in the LAS-AHF trial and underwent LA mechanics analysis by speckle tracking echocardiography. 77 patients were followed-up at 6 and 12- months. At hospital admission, discharge, 6 and 12-months post-discharge, LA reservoir function (LAS), LA pump strain, LAVi, LA stiffness, indicators of right ventricular (RV) and left ventricular (LV) function, congestion indexes (B lines, IVC, X-ray congestion score index) and biomarkers (NT-pro-BNP) were measured. The primary outcome was time to first event of re-hospitalization, worsening HF or cardiovascular death.From admission to discharge, RV function significantly improved after decongestion, while no significant differences were observed in LA dynamics and LV function. In sinus rhythm patients with mild or no mitral regurgitation, decongestion was associated with a significant improvement of LAS and LA pump strain rate during hospitalization. At 12 months, 24 CV events occurred and of LAS impairment at 12 months follow-up emerged as the most powerful predictor followed by NT-pro-BNP. Kaplan-Meier Curves showed a better survival for LAS >16%, improvement of LAS > 5% and a LAS/LAVi ratio >0.25%/ml/m2 compared to lower cutoff values (log-rank: HR 3.5 CI 95% 1.8-7.3, p = 0.004; log-rank: HR 3.6 CI 95% 2-7.9, p < 0.01; log-rank: HR 3.27 CI 95% 1.4-7.7, p = 0.007).<br /><b>Conclusions</b><br />In AHF of any LVEF, LA dynamics is highly predictive of re-hospitalization and cardiovascular outcome and allows to ease risk-stratification, potentially becoming an early reference target for improving long-term outcome.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 31 Oct 2023; epub ahead of print</small></div>

<div><h4>Assessment of left atrioventricular coupling and left atrial function impairment in diabetes with and without hypertension using CMR feature tracking.</h4><i>Shi R, Jiang YN, Qian WL, Guo YK, ... Yang ZG, Li Y</i><br /><b>Purpose</b><br />The study was designed to assess the effect of co-occurrence of diabetes mellitus (DM) and hypertension on the deterioration of left atrioventricular coupling index (LACI) and left atrial (LA) function in comparison to individuals suffering from DM only.<br /><b>Methods</b><br />From December 2015 to June 2022, we consecutively recruited patients with clinically diagnosed DM who underwent cardiac magnetic resonance (CMR) at our hospital. The study comprised a total of 176 patients with DM, who were divided into two groups based on their blood pressure status: 103 with hypertension (DM + HP) and 73 without hypertension (DM-HP). LA reservoir function (reservoir strain (ε<sub>s</sub>), total LA ejection fraction (LAEF)), conduit function (conduit strain (ε<sub>e</sub>), passive LAEF), booster-pump function (booster strain (ε<sub>a</sub>) and active LAEF), LA volume index (LAVI), LV global longitudinal strain (LVGLS), and LACI were evaluated and compared between the two groups.<br /><b>Results</b><br />After adjusting for age, sex, body surface area (BSA), and history of current smoking, total LAEF (61.16 ± 14.04 vs. 56.05 ± 12.72, p = 0.013) and active LAEF (43.98 ± 14.33 vs. 38.72 ± 13.51, p = 0.017) were lower, while passive LAEF (33.22 ± 14.11 vs. 31.28 ± 15.01, p = 0.807) remained unchanged in the DM + HP group compared to the DM-HP group. The DM + HP group had decreased ε<sub>s</sub> (41.27 ± 18.89 vs. 33.41 ± 13.94, p = 0.006), ε<sub>e</sub> (23.69 ± 12.96 vs. 18.90 ± 9.90, p = 0.037), ε<sub>a</sub> (17.83 ± 8.09 vs. 14.93 ± 6.63, p = 0.019), and increased LACI (17.40±10.28 vs. 22.72±15.01, p = 0.049) when compared to the DM-HP group. In patients with DM, multivariate analysis revealed significant independent associations between LV GLS and εs (β=-1.286, p < 0.001), εe (β=-0.919, p < 0.001), and εa (β=-0.324, p = 0.036). However, there was no significant association observed between LV GLS and LACI (β=-0.003, p = 0.075). Additionally, hypertension was found to independently contribute to decreased εa (β=-2.508, p = 0.027) and increased LACI in individuals with DM (β = 0.05, p = 0.011).<br /><b>Conclusions</b><br />In DM patients, LV GLS showed a significant association with LA phasic strain. Hypertension was found to exacerbate the decline in LA booster strain and increase LACI in DM patients, indicating potential atrioventricular coupling index alterations.<br /><br />© 2023. The Author(s).<br /><br /><small>Cardiovasc Diabetol: 30 Oct 2023; 22:295</small></div>

<div><h4>Association of right atrial strain and long-term outcome in severe secondary tricuspid regurgitation.</h4><i>Galloo X, Fortuni F, Meucci MC, Butcher SC, ... Bax JJ, Ajmone Marsan N</i><br /><b>Objective</b><br />Severe secondary tricuspid regurgitation (STR) causes significant right atrial (RA) volume overload, resulting in structural and functional RA-remodelling. This study evaluated whether patients with severe STR and reduced RA function, as assessed by RA-reservoir-strain (RASr), show lower long-term prognosis.<br /><b>Methods</b><br />Consecutive patients, from a single centre, with first diagnosis of severe STR and RASr measure available, were included. Extensive echocardiographic analysis comprised measures of cardiac chamber size and function, assessed also by two-dimensional speckle-tracking strain analysis. Primary outcome was all-cause mortality, analysed from inclusion until death or last follow-up. The association of RASr with the outcome was evaluated by Cox regression analysis and Akaike information criterion.<br /><b>Results</b><br />A total of 586 patients with severe STR (age 68±13 years; 52% male) were included. Patients presented with mild right ventricular (RV) dilatation (end-diastolic area 13.8±6.5 cm<sup>2</sup>/m<sup>2</sup>) and dysfunction (free-wall strain 16.2±7.2%), and with moderate-to-severe RA dilatation (max area 15.0±5.3 cm<sup>2</sup>/m<sup>2</sup>); the median value of RASr was 13%. In the overall population, 10-year overall survival was low (40%, 349 deaths), and was significantly lower in patients with lower RASr (defined by the median value): 36% (195 deaths) for RASr ≤13% compared with 45% (154 deaths) for RASr >13% (log-rank p=0.016). With a median follow-up of 6.6 years, RASr was independently associated with all-cause mortality (HR per 5% RASr increase:0.928; 95% CI 0.864 to 0.996; p=0.038), providing additional value over relevant clinical and echocardiographic covariates (including RA size and RV function/size).<br /><b>Conclusions</b><br />Patients with severe STR presented with significant RA remodelling, and lower RA function, as measured by RASr, was independently associated with all-cause mortality, potentially improving risk stratification in these patients.<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 30 Oct 2023; epub ahead of print</small></div>

<div><h4>Left ventricular strain-volume loops and myocardial fibrosis in pediatric patients with Duchenne muscular dystrophy.</h4><i>Kerstens TP, van Everdingen WM, Ten Cate FEAU, Thijssen DHJ</i><br /><b>Background</b><br />The left ventricular strain-volume loop (SVL) combines changes in global longitudinal strain (GLS) and LV volume across a cardiac cycle, providing insight into cardiac dynamics. This study explored the association between left ventricular SVL and presence of fibrosis, assessed with late gadolinium enhancement, in patients with Duchenne muscular dystrophy (DMD).<br /><b>Methods and results</b><br />34 pediatric patients with DMD were included. Feature tracking analysis was used to assess endocardial GLS and volumetric measurements to construct the SVL. Mean age at the time of assessment was 14 ± 3 and 11 ± 2 years old (p < 0.01) in the group with (n = 18) versus without fibrosis (n = 16), respectively. Left ventricular ejection fraction was not significantly different between groups (fibrosis 56.4 ± 3.8% versus without fibrosis 54.0 ± 6.3%, p = 0.18). After adjusting for age, the late diastolic slope of the SVL was significantly associated with presence of fibrosis (OR 0.39 [95% CI 0.18-0.85]; area under the receiver operating characteristic curve: 0.83 [95% CI 0.70-0.97]) No significant association was observed for peak strain and fibrosis (OR 1.15 [95% CI 0.86-1.546]).<br /><b>Conclusion</b><br />A lower late diastolic slope of the left ventricular SVL, related to the interplay between longitudinal deformation and volume changes late in diastole, is associated with presence of myocardial fibrosis in pediatric patients with DMD.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 30 Oct 2023:131568; epub ahead of print</small></div>

<div><h4>The Pixel Variation Score: an Echocardiographic Index to Assess Temporal Variation of Mitral Regurgitant Flow.</h4><i>Verbeke J, Kamoen V, De Buyzere M, Claessens T, Timmermans F</i><br /><b>Background</b><br />In mitral regurgitation (MR), temporal variation of MR flow has been considered an important reason for inaccurate MR grading. Current echocardiographic methods for assessing temporal MR flow variation are complex, and their clinical relevance has not been investigated. In this study, we investigated whether assessing MR flow variation using a dimensionless index with echocardiography is feasible, clinically meaningful, and related to patient outcomes.<br /><b>Methods</b><br />Consecutive patients with mitral valve prolapse (MVP, n = 244) and functional MR (FMR, n = 396) underwent comprehensive echocardiography. MR severity was assessed using an integrated approach advocated by current guidelines. The MR continuous wave Doppler envelope was divided into three segments of equal duration. Each segment\'s pixel intensity was assessed to calculate the pixel variation score (PVS).<br /><b>Results</b><br />PVS was lower in FMR patients than MVP patients. Lower PVS was associated with worse MR, larger left atrial and left ventricular dimensions, lower ejection fraction, and higher pulmonary artery pressures. In MVP, PVS was significantly associated with postoperative left ventricular reverse remodeling and was able to reclassify most patients in which single-frame measures overestimated MR severity. Finally, PVS had incremental prognostic value on top of clinical and echocardiographic predictors of outcome.<br /><b>Conclusions</b><br />Temporal variation in MR flow can reliably be assessed with echocardiography through analysis of the CWD signal. A high PVS value may alert the echocardiographer to defer from single-frame MR grading and also suggests that the MR is probably not severe.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 30 Oct 2023; epub ahead of print</small></div>

<div><h4>Impact of Myocardial Perfusion and Coronary Calcium on Medical Management for Coronary Artery Disease.</h4><i>Hijazi W, Feng Y, Southern DA, Chew D, ... Berman D, Miller RJH</i><br /><b>Aims</b><br />SPECT myocardial perfusion imaging (MPI) remains one of the most widely used imaging modalities for the diagnosis and prognostication of coronary artery disease (CAD). Despite the extensive prognostic information provided by MPI, little is known about how this influences the prescription of medical therapy for CAD. We evaluated the relationship between MPI with CT attenuation correction and prescription of acetylsalicylic acid (ASA) and statins.<br /><b>Methods and results</b><br />We performed a retrospective analysis of consecutive patients who underwent SPECT MPI at a single center between 2015 and 2021. Myocardial perfusion abnormalities and coronary calcium burden were assessed, with attenuation correction imaging 77.8% of patients. Medication prescriptions before and within 180 days after the test were compared. Associations between abnormal perfusion and calcium burden with ASA and statin prescription were assessed using multivariable logistic regression.In total, 9,908 patients were included, with a mean age 66.8 ± 11.7 years and 5,337(53.9%) males. The prescription of statins increased more in patients with abnormal perfusion (increase of 19.2% vs 12.0%, p < 0.001). Similarly, the presence of extensive CAC led to a greater increase in statin prescription compared to no calcium (increase 12.1% vs 7.8%, p < 0.001). In multivariable analyses, ischemia and coronary artery calcium were independently associated with ASA and statin prescription.<br /><b>Conclusion</b><br />Abnormal MPI testing was associated with significant changes in medical therapy. Both calcium burden and perfusion abnormalities were associated with increased prescriptions of medical therapy for CAD.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Differences in blood flow dynamics between balloon- and self-expandable valves in patients with aortic stenosis undergoing transcatheter aortic valve replacement.</h4><i>Takahashi Y, Kamiya K, Nagai T, Tsuneta S, ... Wakasa S, Anzai T</i><br /><b>Background</b><br />The differences in pre- and early post-procedural blood flow dynamics between the two major types of bioprosthetic valves, the balloon-expandable valve (BEV) and self-expandable valve (SEV), in patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR), have not been investigated. We aimed to investigate the differences in blood flow dynamics between the BEV and SEV using four-dimensional flow cardiovascular magnetic resonance (4D flow CMR).<br /><b>Methods</b><br />We prospectively examined 98 consecutive patients with severe AS who underwent TAVR between May 2018 and November 2021 (58 BEV and 40 SEV) after excluding those without CMR because of a contraindication, inadequate imaging from the analyses, or patients\' refusal. CMR was performed in all participants before (median interval, 22 [interquartile range (IQR) 4-39] days) and after (median interval, 6 [IQR 3-6] days) TAVR. We compared the changes in blood flow patterns, wall shear stress (WSS), and energy loss (EL) in the ascending aorta (AAo) between the BEV and SEV using 4D flow CMR.<br /><b>Results</b><br />The absolute reductions in helical flow and flow eccentricity were significantly higher in the SEV group compared in the BEV group after TAVR (BEV: - 0.22 ± 0.86 vs. SEV: - 0.85 ± 0.80, P < 0.001 and BEV: - 0.11 ± 0.79 vs. SEV: - 0.50 ± 0.88, P = 0.037, respectively); there were no significant differences in vortical flow between the groups. The absolute reduction of average WSS was significantly higher in the SEV group compared to the BEV group after TAVR (BEV: - 0.6 [- 2.1 to 0.5] Pa vs. SEV: - 1.8 [- 3.5 to - 0.8] Pa, P = 0.006). The systolic EL in the AAo significantly decreased after TAVR in both the groups, while the absolute reduction was comparable between the groups.<br /><b>Conclusions</b><br />Helical flow, flow eccentricity, and average WSS in the AAo were significantly decreased after SEV implantation compared to BEV implantation, providing functional insights for valve selection in patients with AS undergoing TAVR. Our findings offer valuable insights into blood flow dynamics, aiding in the selection of valves for patients with AS undergoing TAVR. Further larger-scale studies are warranted to confirm the prognostic significance of hemodynamic changes in these patients.<br /><br />© 2023. Society for Cardiovascular Magnetic Resonance.<br /><br /><small>J Cardiovasc Magn Reson: 26 Oct 2023; 25:60</small></div>

<div><h4>Automatic measurements of left ventricular volumes and ejection fraction by artificial intelligence: Clinical validation in real-time and large databases.</h4><i>Olaisen S, Smistad E, Espeland T, Hu J, ... Løvstakken L, Dalen H</i><br /><b>Background:</b><br/>and aims</b><br />Echocardiography is a cornerstone in cardiac imaging and left ventricular (LV) ejection fraction (EF) is a key parameter for patient management. Recent advances in artificial intelligence (AI) have enabled fully automatic measurements of LV volumes and EF both during scanning and in stored recordings. The aim of this study was to evaluate the impact of implementing AI measurements on acquisition and processing time and test-retest reproducibility compared to standard clinical workflow, as well as to study the agreement with reference in large internal and external databases.<br /><b>Methods</b><br />Fully automatic measurements of LV volumes and EF by a novel AI software were compared to manual measurements in the following clinical scenarios: 1) In real-time use during scanning of 50 consecutive patients, 2) in 40 subjects with repeated echocardiographic examinations and manual measurements by four readers, and 3) in large internal and external research databases of 1881 and 849 subjects, respectively.<br /><b>Results</b><br />Real-time AI measurements significantly reduced the total acquisition and processing time by 77% (median 5.3 minutes, p < 0.001) compared to standard clinical workflow. Test-retest reproducibility of AI measurements was superior in inter-observer scenarios and non-inferior in intra-observer scenarios. AI measurements showed good agreement with reference measurements both in real-time and in large research databases.<br /><b>Conclusions</b><br />The software reduced the time taken to perform and volumetrically analyse routine echocardiograms without a decrease in accuracy compared to experts.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 26 Oct 2023; epub ahead of print</small></div>

<div><h4>Right ventricular free wall and four-chamber longitudinal strain in relation to incident heart failure in the general population.</h4><i>Espersen C, Skaarup KG, Lassen MCH, Johansen ND, ... Møgelvang R, Biering-Sørensen T</i><br /><b>Background</b><br />Right ventricular free wall (RVFWLS) and four-chamber longitudinal strain (RV4CLS) are associated with adverse events in various patient populations including patients with heart failure (HF). We sought to investigate the prognostic value of RVFWLS and RV4CLS for the development of incident HF in participants from the general population.<br /><b>Methods</b><br />Participants from the 5th Copenhagen City Heart Study (2011-2015) without known chronic ischemic heart disease or HF at baseline were included. RVFWLS and RV4CLS were obtained using two-dimensional speckle-tracking echocardiography from the RV-focused apical four-chamber view. The primary endpoint was incident HF.<br /><b>Results</b><br />Among 2,740 participants (mean age 54 ± 17 years, 42% male), 43 (1.6%) developed HF during a median follow-up of 5.5 years (IQR 4.5-6.3). Both RVFWLS and RV4CLS were associated with an increased risk of incident HF during follow-up independent of age, sex, hypertension, diabetes, body mass index and tricuspid annular plane systolic excursion (TAPSE), (HR 1.06, 95%CI 1.00-1.11, p = 0.034, per 1% absolute decrease and HR 1.14, 95%CI 1.05-1.23, p = 0.001, per 1% absolute decrease, respectively). Left ventricular ejection fraction (LVEF) modified the association between RV4CLS and incident HF (p for interaction = 0.016) such that RV4CLS was only of prognostic importance among those with LVEF < 55% (HR 1.21, 95%CI 1.11-1.33, p < 0.001 vs. HR 0.94, 95%CI 0.80-1.10, p = 0.43 in patients with LVEF ≥ 55%).<br /><b>Conclusions</b><br />In participants from the general population, both RVFWLS and RV4CLS were associated with an increased risk of incident HF independent of important baseline characteristics and TAPSE, and LVEF modified the relationship between RV4CLS and incident HF.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 25 Oct 2023; epub ahead of print</small></div>

<div><h4>Oscillatory Shear Stress is Elevated in Patients with Bicuspid Aortic Valve and Aortic Regurgitation: A 4D Flow CMR Cross-Sectional Study.</h4><i>Trenti C, Fedak PWM, White JA, Garcia J, Dyverfeldt P</i><br /><b>Aims</b><br />Patients with bicuspid aortic valve (BAV) and aortic regurgitation have higher rate of aortic complications compared to patients with BAV and stenosis, as well as BAV without valvular disease. Aortic regurgitation alters blood hemodynamics not only in systole, but also during diastole. We therefore sought to investigate wall shear stress (WSS) during the whole cardiac cycle in BAV with aortic regurgitation.<br /><b>Methods and results</b><br />Fifty-seven subjects that underwent 4D flow cardiovascular magnetic resonance imaging were included: 13 patients with BAVs without valve disease, 14 BAVs with aortic regurgitation, 15 BAVs with aortic stenosis and 22 normal controls with tricuspid aortic valve (TAV). Peak and time averaged WSS in systole and diastole, and the oscillatory shear index (OSI) in the ascending aorta were computed. Student\'s t-tests were used to compare values between the four groups where the data were normally distributed, and the non-parametric Wilcoxon rank sum tests were used otherwise. BAVs with regurgitation had similar peak and time averaged WSS compared to the patients with BAV without valve disease and with stenosis, and no regions of elevated WSS were found. BAV with aortic regurgitation had twice as high OSI as the other groups (p ≤ 0.001), and mainly in the outer mid-to-distal ascending aorta.<br /><b>Conclusion</b><br />OSI uniquely characterizes altered WSS patterns in BAVs with aortic regurgitation, and thus could be a hemodynamic marker specific for this specific group which is at higher risk of aortic complications. Future longitudinal studies are needed to verify this hypothesis.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 25 Oct 2023; epub ahead of print</small></div>

<div><h4>Left Atrial Strain Predicts Stroke Recurrence and Death in Patients With Cryptogenic Stroke.</h4><i>Vera A, Cecconi A, Ximénez-Carrillo Á, Ramos C, ... Alfonso F, DECRYTORING study investigators</i><br /><AbstractText>Left atrial strain (LAS) has been widely studied as a predictor of atrial fibrillation (AF) after cryptogenic stroke (CS). However, the evidence about its prognostic role in terms of stroke recurrence and death in this setting remains scarce. A total of 92 consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography, including LAS was performed during admission. The primary outcome measure was the composite of stroke recurrence or death. The mean age was 77.5 ± 7.7, and 58% of patients were female. After a median follow up of 28 months, the primary outcome measure occurred in 15 patients (16%). The primary outcome was more frequent in patients with diabetes (53% vs 21%, p = 0.02), chronic kidney disease (33% vs 10%, p = 0.034), and a history of heart failure (13% vs 0%, p = 0.025). LAS reservoir (LASr) and LAS conduit (LAScd) were lower in patients developing the primary outcome (21% ± 7% vs 28.8% ± 11%, p = 0.017 and 7.7% ± 3.9% vs 13.7% ± 7%, p = 0.007, respectively). On multivariate analysis, LASr (hazard ratio 0.9, 95% confidence interval 0.85 to 0.99, p = 0.048) and diabetes (hazard ratio 3.3, 95% confidence interval 1.03 to 10.4, p = 0.045) were associated with stroke recurrence or all-cause death after CS. On the log-rank test (using the discriminatory cut-off value of LASr <23%), LASr (p = 0.009) was associated with higher risk of the primary outcome. In conclusion, lower values of the LAS reservoir were associated with a higher risk of stroke recurrence or death after CS. LAS may identify patients at higher risk of thromboembolism and stress conditions.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 25 Oct 2023; epub ahead of print</small></div>

<div><h4>Cardiac Dysfunction Rather Than Aortic Valve Stenosis Severity Drives Exercise Intolerance and Adverse Hemodynamics.</h4><i>Hoedemakers S, Verwerft J, Reddy YNV, Delvaux R, ... Herbots L, Verbrugge FH</i><br /><b>Aims</b><br />To study the impact of heart failure with preserved ejection fraction (HFpEF) versus aortic stenosis (AS) lesion severity on left ventricular (LV) hypertrophy, diastolic dysfunction, left atrial (LA) dysfunction, hemodynamics, and exercise capacity.<br /><b>Methods and results</b><br />Patients (n = 206) with at least moderate AS (aortic valve area ≤0.85 cm/m2) and discordant symptoms underwent cardiopulmonary exercise testing with simultaneous echocardiography. The population was stratified according to the probability of underlying HFpEF by the H2FPEF score [0-5 (AS/HFpEF-) vs. 6-9 points (AS/HFpEF+)] and AS severity (Moderate vs. Severe). Mean age was 73 ± 10 years with 40% women. Twenty-eight patients had Severe AS/HFpEF + (14%), 111 Severe AS/HFpEF- (54%), 13 Moderate AS/HFpEF + (6%), and 54 Moderate AS/HFpEF- (26%). AS/HFpEF + versus AS/HFpEF- patients, irrespective of AS severity, had a lower LV global longitudinal strain, impaired diastolic function, reduced LV compliance, and more pronounced LA dysfunction. The pulmonary arterial pressure-cardiac output slope was significantly higher in AS/HFpEF + versus AS/HFpEF- (5.4 ± 3.1 vs. 3.9 ± 2.2 mmHg/L/min, respectively; p = 0.003), mainly driven by impaired cardiac output and chronotropic reserve, with signs of right ventricular-pulmonary arterial uncoupling. AS/HFpEF + versus AS/HFpEF- was associated with a lower peak aerobic capacity (11.5 ± 3.7 vs. 15.9 ± 5.9 mL/min/kg, respectively; p < 0.0001), but did not differ between Moderate and Severe AS (14.7 ± 5.5 vs. 15.2 ± 5.9 mL/min/kg, respectively; p = 0.6).<br /><b>Conclusions</b><br />A high H2FPEF score is associated with a reduced exercise capacity and adverse hemodynamics in patients with moderate to severe AS. Both exercise performance and hemodynamics correspond better with intrinsic cardiac dysfunction than AS severity.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 24 Oct 2023; epub ahead of print</small></div>

<div><h4>Echocardiographic Reference Ranges of Global Longitudinal Strain for All Cardiac Chambers Using Guideline-Directed Dedicated Views.</h4><i>Nyberg J, Jakobsen EO, Østvik A, Holte E, ... Grenne B, Dalen H</i><br /><b>Background</b><br />Myocardial deformation by echocardiographic strain imaging is a key measurement in cardiology, providing valuable diagnostic and prognostic information. Reference ranges for strain should be established from large healthy populations with minimal methodologic biases and variability.<br /><b>Objectives</b><br />The aim of this study was to establish echocardiographic reference ranges, including lower normal limits of global strains for all 4 cardiac chambers, by guideline-directed dedicated views from a large healthy population and to evaluate the influence of subject-specific characteristics on strain.<br /><b>Methods</b><br />In total, 1,329 healthy participants from HUNT4Echo, the echocardiographic substudy of the fourth wave of the Trøndelag Health Study, were included. Echocardiographic recordings specific for each chamber were optimized according to current recommendations. Two experienced sonographers recorded all echocardiograms using GE HealthCare Vivid E95 scanners. Analyses were performed by experts using GE HealthCare EchoPAC.<br /><b>Results</b><br />The reference ranges for left ventricular (LV) global longitudinal strain and right ventricular free-wall strain were -24% to -16% and -35% to -17%, respectively. Correspondingly, left atrial (LA) and right atrial (RA) reservoir strains were 17% to 49% and 17% to 59%. All strains showed lower absolute values with higher age, except for LA and RA contractile strains, which were higher. The feasibility for strain was overall good (LV 96%, right ventricular 83%, LA 94%, and RA 87%). All chamber-specific strains were associated with age, and LV strain was associated with sex.<br /><b>Conclusions</b><br />Reference ranges of strain for all cardiac chambers were established based on guideline-directed chamber-specific recordings. Age and sex were the most important factors influencing reference ranges and should be considered when using strain echocardiography.<br /><br />Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>JACC Cardiovasc Imaging: 24 Oct 2023; epub ahead of print</small></div>

<div><h4>Amulet device implantation following incomplete left atrial appendage closure with Watchman legacy device.</h4><i>Yoon SH, Elgendy AY, Dallan LAP, Filby SJ</i><br /><AbstractText>Peri-device leak after left atrial appendage closure (LAAC) is often treated with endovascular coils, plugs, or second occluders. This is the first study reporting the Amulet device used for peri-device leak. An 80-year-old male with paroxysmal atrial fibrillation and recurrent falls with head trauma who underwent LAAC with a 24 mm Watchman 2.5 device 3 years ago at another institution was referred to our clinic for management of the peri-device leak. Transesophageal echocardiogram showed persistent residual peri-device leak with 5 mm width along the Coumadin ridge aspect of the device. Computed tomography (CT) also showed the peri-device leak with width of 6 mm and complete opacification of left atrial appendage (LAA). Importantly, CT demonstrated that the Watchman 2.5 device was deployed at distal LAA, leaving the proximal part of LAA with length of 10 mm from ostium. Under general anesthesia, a 22 mm Amulet device was deployed successfully with complete sealing of LAA. Procedure planning is the key to minimize the risk of peri-device leak or device-related thrombosis. Careful assessment of LAA anatomy using multimodality images for peri-device leak after LAAC helped optimal treatment strategy including second LAAC with different type of devices.</AbstractText><br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 23 Oct 2023; epub ahead of print</small></div>

<div><h4>Echocardiographic Characteristics of Left and Right Ventricular Longitudinal Function in Patients with a History of Cardiac Surgery.</h4><i>Kuwajima K, Ogawa M, Ruiz I, Hasegawa H, ... Siegel RJ, Shiota T</i><br /><AbstractText>Previous studies have indicated a reduction in right ventricular (RV) longitudinal motion following cardiac surgery. However, the long-term effect of cardiac surgery on longitudinal motion and the involvement of left ventricular (LV) motion remain unclear. Therefore, this study aimed to comprehensively investigate the longitudinal function of the right ventricle and left ventricle in patients who had undergone cardiac surgery. The study included patients who underwent comprehensive transthoracic echocardiography (TTE) with three-dimensional RV data sets. By propensity score matching of clinical and echocardiographic variables, including LV and RV ejection fraction, the echocardiographic parameters were compared between patients with and without a history of cardiac surgery (the surgery and nonsurgery groups, respectively). In this study, the surgery group had significantly lower LV global longitudinal strain values than the nonsurgery group, despite having similar LV ejection fraction. Tricuspid annular plane systolic excursion (TAPSE), tricuspid annular velocity, and RV free wall longitudinal strain were also significantly smaller in the surgery group, whereas the RV ejection fraction was comparable between the 2 groups. Additionally, a subgroup analysis based on the time from previous surgery to TTE (≤1 and >1 year) revealed that TAPSE was reduced in both postoperative phases. In conclusion, LV and RV longitudinal parameters were reduced after cardiac surgery, despite preserved LV and RV global functions. Moreover, TAPSE was reduced even a long time following cardiac surgery. These findings emphasize the need for careful interpretation of biventricular longitudinal motion in patients with a history of cardiac surgery.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Am J Cardiol: 22 Oct 2023; epub ahead of print</small></div>

<div><h4>Increasing frequency of dyspnea among patients referred for cardiac stress testing.</h4><i>Rozanski A, Gransar H, Sakul S, Miller RJH, ... Thomson LEJ, Berman DS</i><br /><b>Objective</b><br />To assess the frequency, change in prevalence, and prognostic significance of dyspnea among contemporary patients referred for cardiac stress testing.<br /><b>Patients and methods</b><br />We evaluated the prevalence of dyspnea and its relationship to all-cause mortality among 33,564 patients undergoing stress/rest SPECT-MPI between January 1, 2002 and December 31, 2017. Dyspnea was assessed as a single-item question. Patients were divided into three temporal groups.<br /><b>Results</b><br />The overall prevalence of dyspnea in our cohort was 30.2%. However, there was a stepwise increase in the temporal prevalence of dyspnea, which was present in 25.6% of patients studied between 2002 and 2006, 30.5% of patients studied between 2007 and 2011, and 38.7% of patients studied between 2012 and 2017. There was a temporal increase in the prevalence of dyspnea in each age, symptom, and risk factor subgroup. The adjusted hazard ratio for mortality was higher among patients with dyspnea vs those without dyspnea both among all patients, and within each chest pain subgroup.<br /><b>Conclusions</b><br />Dyspnea has become increasingly prevalent among patients referred for cardiac stress testing and is now present among nearly two-fifths of contemporary cohorts referred for stress-rest SPECT-MPI. Prospective study is needed to standardize the assessment of dyspnea and evaluate the reasons for its increasing prevalence.<br /><br />© 2023. The Author(s) under exclusive licence to American Society of Nuclear Cardiology.<br /><br /><small>J Nucl Cardiol: 20 Oct 2023; epub ahead of print</small></div>

<div><h4>Imaging in patients with cardiovascular implantable electronic devices - Part 1: Imaging before and during device implantation.</h4><i>Stankovic I, Voigt JU, Burri H, Muraru D, ... Smiseth OA, Donal E</i><br /><AbstractText>More than 500,000 cardiovascular implantable electronic devices (CIED) are implanted in the European Society of Cardiology countries each year. The role of cardiovascular imaging in patients being considered for CIED is distinctly different from imaging in CIED recipients. In the former group, imaging can help identify specific or potentially reversible causes of heart block, the underlying tissue characteristics associated with malignant arrhythmias, the mechanical consequences of conduction delays and can also aid challenging lead placements. On the other hand, cardiovascular imaging is required in CIED recipients both for standard indications, and to assess the response to device implantation, to diagnose immediate and delayed complications after implantation, and to guide device optimization. The present clinical consensus statement (Part 1) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date and evidence-based guidance to cardiologists, cardiac imagers and pacing specialists regarding the use of imaging in patients undergoing implantation of conventional pacemakers, cardioverter defibrillators and resynchronization therapy devices. The document summarizes the existing evidence regarding the use of imaging in patient selection and during the implantation procedure and also underlines gaps in evidence in the field. The role of imaging after CIED implantation is discussed in the second document (Part 2).</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 20 Oct 2023; epub ahead of print</small></div>

<div><h4>Tricuspid edge-to-edge repair for tricuspid valve prolapse and flail leaflet. Feasibility in comparison to patients with secondary tricuspid regurgitation.</h4><i>Dannenberg V, Bartko PE, Andreas M, Bartunek A, ... Rudolph V, Ivannikova M</i><br /><b>Aims</b><br />Transcatheter tricuspid edge-to-edge repair (T-TEER) has gained widespread use for the treatment of tricuspid regurgitation in symptomatic patients with high operative risk. Although secondary TR is the most common pathology, some patients exhibit primary or predominantly primary TR. Characterization of patients with these pathologies in the T-TEER context has not been systematically performed.<br /><b>Methods and results</b><br />Patients assigned to T-TEER by the interdisciplinary Heart Team were consecutively recruited in two European centers over 4 years. Echocardiographic images were evaluated to distinguish between primary and secondary causes of TR. Both groups were compared concerning procedural results. 339 patients were recruited, 13% with primary TR and 87% with secondary TR. Patients with primary TR had a smaller right ventricle (basal diameter 45 vs. 49 mm, p = 0.004), a better right ventricular function (fractional area change 45 vs. 41%, p = 0.001), a smaller right (28 vs. 34cm², p = 0.021) and left (52 vs. 67 ml/m², p = 0.038) atrium, and a better left ventricular ejection fraction (60 vs. 52%, p = 0.005). The severity of TR was similar in primary and secondary TR at baseline (TR vena contracta width pre-interventional 13 ± 4 vs. 14 ± 5 mm, p = 0.19), and T-TEER significantly reduced TR in both groups (TR vena contracta width post-interventional 4 ± 3 vs. 5 ± 5 mm, p = 0.10). These findings remained stable after propensity score matching. Complications were similar between both groups.<br /><b>Conclusion</b><br />T-TEER confers equally safe and effective reduction of TR in patients with primary and secondary TR.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 20 Oct 2023; epub ahead of print</small></div>

<div><h4>Imaging in patients with cardiovascular implantable electronic devices - Part 2: Imaging after device implantation.</h4><i>Stankovic I, Voigt JU, Burri H, Muraru D, ... Smiseth OA, Donal E</i><br /><AbstractText>Cardiac implantable electronic devices (CIED) improve quality of life and prolong survival, but there are additional considerations for cardiovascular imaging after implantation - both for standard indications and for diagnosing and guiding management of device-related complications. This clinical consensus statement (Part 2) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date and evidence-based guidance to cardiologists, cardiac imagers and pacing specialists regarding the use of imaging in patients after implantation of conventional pacemakers, cardioverter defibrillators and resynchronization therapy devices. The document summarizes the existing evidence regarding the role and optimal use of various cardiac imaging modalities in patients with suspected CIED-related complications and also discusses CRT optimization, the safety of magnetic resonance imaging in CIED carriers, and describes the role of chest radiography in assessing CIED type, position, and complications. The role of imaging before and during CIED implantation is discussed in a companion document (Part 1).</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 20 Oct 2023; epub ahead of print</small></div>

<div><h4>Prognostic significance and clinical utility of left atrial reservoir strain in transcatheter aortic valve replacement.</h4><i>von Roeder M, Maeder M, Wahl V, Kitamura M, ... Lurz P, Abdel-Wahab M</i><br /><b>Aims</b><br />Patients with diastolic dysfunction (DD) experience worse outcomes after transcatheter aortic valve replacement (TAVR). We investigated the prognostic value and clinical utility of left atrial reservoir strain (LARS) in patients undergoing TAVR for aortic stenosis (AS).<br /><b>Methods and results</b><br />All consecutive patients undergoing TAVR between 01/2018 and 12/2018 were included if discharge echocardiography and follow-up were available. LARS was derived from 2-D-speckle-tracking. Patients were grouped into 3 tertiles according to LARS. DD was analyzed using the ASE/EACVI-algorithm. The primary outcome was a composite of all-cause death and readmission for worsening heart failure 12 months after TAVR. Overall, 606 patients were available (age 80 years, interquartile range [IQR] 77-84), including 53% women. Median LARS was 13.0% (IQR 8.4-18.3). Patients were classified by LARS tertiles (mildly-impaired 21.4% [IQR 18.3-24.5], moderately-impaired 13.0% [IQR 11.3-14.6], severely-impaired 7.1% [IQR 5.4-8.4], p<0.0001). The primary outcome occurred more often in patients with impaired LARS (mildly-impaired 7.4%, moderately-impaired 13.4%, severely-impaired 25.7%, p<0.0001). On adjusted multivariable Cox-regression analysis, LARS-tertiles (HR 0.62, 95% CI 0.44-0.86, p=0.005) and higher degree of tricuspid regurgitation (HR 1.82, 95% CI 1.23-2.98, p=0.003) were the only significant predictors of the primary endpoint. Importantly, DD was unavailable in 56% of patients, but LARS-assessment allowed for reliable prognostication regarding the primary endpoint in subgroups without DD assessment (HR 0.64, 95% CI 0.47-0.87, p=0.003).<br /><b>Conclusions</b><br />Impaired LARS is independently associated with worse outcomes in patients undergoing TAVR. LARS allows for risk-stratification at discharge even in patients where DD cannot be assessed by conventional echocardiographic means.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 20 Oct 2023; epub ahead of print</small></div>

<div><h4>Transseptal puncture in left atrial appendage closure guided by 3D printing and multiplanar CT reconstruction.</h4><i>Hozman M, Herman D, Zemanek D, Fiser O, ... Pokorny T, Osmancik P</i><br /><b>Background</b><br />The presented study investigates the application of bi-arterial 3D printed models to guide transseptal puncture (TSP) in left atrial appendage closure (LAAC).<br /><b>Aims</b><br />The objectives are to (1) test the feasibility of 3D printing (3DP) for TSP guidance, (2) analyse the distribution of the optimal TSP locations, and (3) define a CT-derived 2D parameter suitable for predicting the optimal TSP locations.<br /><b>Methods</b><br />Preprocedural planning included multiplanar CT reconstruction, 3D segmentation, and 3DP. TSP was preprocedurally simulated in vitro at six defined sites. Based on the position of the sheath, TSP sites were classified as optimal, suboptimal, or nonoptimal. The aim was to target the TSP in the recommended position during the procedure. Procedure progress was assessed post hoc by the operator.<br /><b>Results</b><br />Of 68 screened patients, 60 patients in five centers (mean age of 74.68 ± 7.64 years, 71.66% males) were prospectively analyzed (3DP failed in one case, and seven patients did not finally undergo the procedure). In 55 patients (91.66%), TSP was performed in the optimal location as recommended by the 3DP. The optimal locations for TSP were postero-inferior in 45.3%, mid-inferior in 45.3%, and antero-inferior in 37.7%, with a mean number of optimal segments of 1.34 ± 0.51 per patient. When the optimal TSP location was achieved, the procedure was considered difficult in only two (3.6%) patients (but in both due to complicated LAA anatomy). Comparing anterior versus posterior TSP in 2D CCT, two parameters differed significantly: (1) the angle supplementary to the LAA ostium and the interatrial septum angle (160.83° ± 9.42° vs. 146.49° ± 8.67°; p = 0.001), and (2) the angle between the LAA ostium and the mitral annulus (95.02° ± 3.73° vs. 107.38° ± 6.76°; p < 0.001), both in the sagittal plane.<br /><b>Conclusions</b><br />In vitro TSP simulation accurately determined the optimal TSP locations for LAAC and facilitated the procedure. More than one-third of the optimal TSP sites were anterior.<br /><br />© 2023 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 19 Oct 2023; epub ahead of print</small></div>

<div><h4>ACC/AHA/ASE/ASNC/ASPC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2023 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Chronic Coronary Disease.</h4><i>Winchester DE, Maron DJ, Blankstein R, Chang IC, ... Russell R, Sandhu AT</i><br /><AbstractText>The American College of Cardiology (ACC) Foundation, along with key specialty and subspecialty societies, conducted an appropriate use review of stress testing and anatomic diagnostic procedures for risk assessment and evaluation of known or suspected chronic coronary disease (CCD), formerly referred to as stable ischemic heart disease (SIHD). This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging, stress echocardiography (echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. As with the prior version of this document, rating of test modalities is provided side-by-side for a given clinical scenario. These ratings are explicitly not considered competitive rankings due to the limited availability of comparative evidence, patient variability, and the range of capabilities available in any given local setting<sup>1-4</sup>.This version of the AUC for CCD is a focused update of the prior version of the AUC for SIHD<sup>4</sup>. Key changes beyond the updated ratings based on new evidence include the following: 1. Clinical scenarios related to preoperative testing were removed and will be incorporated into another AUC document under development. 2. Some clinical scenarios and tables were removed in an effort to simplify the selection of clinical scenarios. Additionally, the flowchart of tables has been reorganized, and all clinical scenario tables can now be reached by answering a limited number of clinical questions about the patient, starting with the patient\'s symptom status. 3. Several clinical scenarios have been revised to incorporate changes in other documents such as pretest probability assessment, atherosclerotic cardiovascular disease (ASCVD) risk assessment, syncope, and others. ASCVD risk factors that are not accounted for in contemporary risk calculators have been added as modifiers to certain clinical scenarios. The 64 clinical scenarios rated in this document are limited to the detection and risk assessment of CCD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines.<sup>5</sup> These clinical scenarios do not specifically address patients having acute chest pain episodes. They may, however, be applicable in the inpatient setting if the patient is not having an acute coronary syndrome and warrants evaluation for CCD.Using standardized methodology, clinical scenarios were developed to describe common patient encounters in clinical practice focused on common applications and anticipated uses of testing for CCD. Where appropriate, the scenarios were developed on the basis of the most current ACC/American Heart Association guidelines. A separate, independent rating panel scored the clinical scenarios in this document on a scale of 1 to 9, following a modified Delphi process consistent with the recently updated AUC development methodology. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented, midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is rarely appropriate.</AbstractText><br /><br />© 2023. Society for Cardiovascular Magnetic Resonance.<br /><br /><small>J Cardiovasc Magn Reson: 19 Oct 2023; 25:58</small></div>

<div><h4>Outcomes of patients with early calcific aortic valve disease detected by clinically indicated echocardiography.</h4><i>Moore MK, Jones GT, Whalley G, Prendergast B, Williams MJA, Coffey S</i><br /><b>Background</b><br />Previous studies have demonstrated relatively slow rates of progression of early calcific aortic valve disease (CAVD), which encompasses aortic sclerosis (ASc) and mild aortic stenosis (AS). The potential evolution to clinically significant AS is unclear and we therefore examined the long-term outcomes of patients with ASc and mild AS detected at the time of clinically indicated echocardiography.<br /><b>Methods</b><br />Data from initial clinically indicated echocardiograms performed between 2010-2018 in patients aged ≥18 years were extracted and linked to nationally collected outcome data. Those with impaired right or left systolic ventricular function or other significant valve disease were excluded. A time to first event analysis was performed with a composite primary outcome of cardiovascular death and aortic valve intervention (AVI).<br /><b>Results</b><br />Of the 13,313 patients, 8,973 had no CAVD, 3,436 had ASc, and 455 had mild AS. The remainder had moderate or worse stenosis. Over a median follow up period of 4.2 (IQR 1.8-6.7) years (and after adjustment for age and sex), those with ASc were at greater risk of the primary outcome (HR 2.9, 95% CI 2.1-4.0) and need for AVI (HR 26.8, 95% CI 9.1-79.1) compared to those with no CAVD. Clinical event rates accelerated after approximately five years in those with mild AS.<br /><b>Conclusion</b><br />Patients with ASc are >25 times more likely to require AVI than those with no CAVD and follow up echocardiography should be considered within 3-4 years in those with mild AS.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 17 Oct 2023; epub ahead of print</small></div>

<div><h4>Comprehensive Myocardial Assessment by Computed Tomography: Impact on Short-Term Outcomes After Transcatheter Aortic Valve Replacement.</h4><i>Koike H, Fukui M, Treibel T, Stanberry LI, ... Lesser JR, Cavalcante JL</i><br /><b>Background</b><br />Quantification of myocardial changes in severe aortic stenosis (AS) is prognostically important. The potential for comprehensive myocardial assessment pre-transcatheter aortic valve replacement (TAVR) by computed tomography angiography (CTA) is unknown.<br /><b>Objectives</b><br />The study sought to evaluate whether quantification of left ventricular (LV) extracellular volume-a marker of myocardial fibrosis-and global longitudinal strain-a marker of myocardial deformation-at baseline CTA associate with post-TAVR outcomes.<br /><b>Methods</b><br />Consecutive patients with symptomatic severe AS between January 2021 and June 2022 who underwent pre-TAVR CTA were included. Computed tomography extracellular volume (CT-ECV) was derived from septum tracing after generating the 3-dimensional CT-ECV map. Computed tomography global longitudinal strain (CT-GLS) used semi-automated feature tracking analysis. The clinical endpoint was the composite outcome of all-cause mortality and heart failure hospitalization.<br /><b>Results</b><br />Among the 300 patients (80.0 ± 9.4 years of age, 45% female, median Society of Thoracic Surgeons Predicted Risk of Mortality score 2.80%), the left ventricular ejection fraction (LVEF) was 58 ± 12%, the median CT-ECV was 28.5% (IQR: 26.2% to 32.1%), and the median CT-GLS was -20.1% (IQR: -23.8% to -16.3%). Over a median follow-up of 16 months (IQR: 12 to 22 months), 38 deaths and 70 composite outcomes occurred. Multivariable Cox proportional hazards model, accounting for clinical and echocardiographic variables, demonstrated that CT-ECV (HR: 1.09 [95% CI: 1.02-1.16]; P = 0.008) and CT-GLS (HR: 1.07 [95% CI: 1.01-1.13]; P = 0.017) associated with the composite outcome. In combination, elevated CT-ECV and CT-GLS (above median for each) showed a stronger association with the outcome (HR: 7.14 [95% CI: 2.63-19.36]; P < 0.001).<br /><b>Conclusions</b><br />Comprehensive myocardial quantification of CT-ECV and CT-GLS associated with post-TAVR outcomes in a contemporary low-risk cohort with mostly preserved LVEF. Whether these imaging biomarkers can be potentially used for the decision making including timing of AS intervention and post-TAVR follow-up will require integration into future clinical trials.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>JACC Cardiovasc Imaging: 17 Oct 2023; epub ahead of print</small></div>

<div><h4>Safety of dobutamine or adenosine stress cardiac magnetic resonance imaging in patients with left ventricular thrombus.</h4><i>Weberling LD, Seitz S, Salatzki J, Ochs A, ... André F, Steen H</i><br /><b>Background</b><br />Left ventricular (LV) thrombus formation is a common but potentially serious complication, typically occurring after myocardial infarction. Due to perceived high thromboembolic risk and lack of safety data, stress cardiac magnetic resonance (CMR) imaging especially with dobutamine is usually avoided despite its high diagnostic yield. This study aimed to investigate the characteristics, safety and outcome of patients with LV thrombus undergoing dobutamine or vasodilator stress CMR.<br /><b>Methods</b><br />Patients undergoing stress CMR with concomitant LV thrombus were retrospectively included. Risk factors, comorbidities, and previous embolic events were recorded. Periprocedural safety was assessed for up to 48 h following the examination. Major adverse cardiac events (MACE) 12 months before the diagnosis were compared to 12 months after the exam and between patients and a matched control group. Additionally, patients were followed up for all-cause mortality.<br /><b>Results</b><br />95 patients (78 male, 65 ± 10.7 years) were included. Among them, 43 patients underwent dobutamine (36 high-dose, 7 low-dose) and 52 vasodilator stress CMR. Periprocedural safety was excellent with no adverse events. During a period of 24 months, 27 MACE (14.7%) occurred in patients and controls with no statistical difference between groups. During a median follow-up of 33.7 months (IQR 37.6 months), 6 deaths (6.3%) occurred. Type of stress agent, thrombus mobility, or protrusion were not correlated to embolic events or death.<br /><b>Conclusion</b><br />The addition of a stress test to a CMR exam is safe and does increase the generally high cardioembolic event rate in LV thrombus patients. Therefore, it is useful to support reperfusion decision-making.<br /><br />© 2023. The Author(s).<br /><br /><small>Clin Res Cardiol: 16 Oct 2023; epub ahead of print</small></div>

<div><h4>Association of pulmonary transit time by cardiac magnetic resonance with heart failure hospitalization in a large prospective cohort with diverse cardiac conditions.</h4><i>Cao JJ, Nashta NF, Weber J, Bano R, ... Grgas M, Gliganic K</i><br /><b>Background</b><br />Longer pulmonary transit time (PTT) is closely associated with hemodynamic abnormalities. However, the implications on heart failure (HF) risk have not been investigated broadly in patients with diverse cardiac conditions. In this study we examined the long-term risk of HF hospitalization associated with longer PTT in a large prospective cohort with a broad spectrum of cardiac conditions.<br /><b>Methods</b><br />All subjects were prospectively recruited to undergo cardiac magnetic resonance (CMR). The dynamic images of first-pass perfusion were acquired to assess peak-to-peak pulmonary transit time (PTT) which was subsequently normalized to RR interval duration. The risk of HF was examined using Cox proportional hazards models adjusted for baseline confounding risk factors.<br /><b>Results</b><br />Among 506 consecutively consented patients undergoing clinical cardiac MR with diverse cardiac conditions, the mean age was 63 ± 14 years and 373 (73%) were male. After a mean follow up duration of 4.5 ± 3.0 years, 70 (14%) patients developed hospitalized HF and of these 6 died. A normalized PTT ≥ 8.2 was associated with a significantly increased adjusted HF hazard ratio of 3.69 (95% CI 2.02, 6.73). The HF hazard ratio was 1.26 (95% CI 1.18, 1.33) for each 1 unit increase in PTT which was higher among those preserved (1.70, 95% CI 1.20, 2.41) compared to those with reduced left ventricular ejection fraction (< 50%) (1.18, 95% CI 1.09, 1.27). PTT remained a significant risk factor of hospitalized HF after additional adjustment for N-terminal pro-hormone brain natriuretic peptide (NT-proBNP) or left ventricular global longitudinal strain with additionally demonstrated incremental model improvement through likelihood ratio testing.<br /><b>Conclusions</b><br />Our findings support the role of PTT in assessing HF risk among patients with broad spectrum of cardiac conditions with reduced as well as preserved ejection fraction. Longer PTT duration is an incremental risk factor for HF when baseline global longitudinal strain and NT-proBNP are taken into consideration.<br /><br />© 2023. Society for Cardiovascular Magnetic Resonance.<br /><br /><small>J Cardiovasc Magn Reson: 12 Oct 2023; 25:57</small></div>

<div><h4>PostAblation cardiac Magnetic resonance to asses Ventricular Tachycardia recurrence (PAM-VT study).</h4><i>Roca-Luque I, Vázquez-Calvo S, Garre P, Ortiz-Perez JT, ... Brugada J, Mont L</i><br /><b>Aims</b><br />Conducting channels (CCs) detected by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) are related to ventricular tachycardia (VT). The aim of this work was to study the ability of postablation LGE-CMR to evaluate ablation lesions.<br /><b>Methods</b><br />This is a prospective study of consecutive patients referred for a scar-related VT ablation. LGE-CMR was performed 6-12 months prior to ablation and 3-6 months after ablation. Scar characteristics of pre- and postablation LGE-CMR were compared.<br /><b>Results</b><br />During the study period (March 2019-April 2021), 61 consecutive patients underwent scar-related VT ablation after LGE-CMR. Overall, 12 patients were excluded (4 had poor-quality LGE-CMR, 2 died before postablation LGE-CMR and 6 underwent postablation LGE-CMR 12 months after ablation). Finally, 49 patients (age:65.5 ± 9.8 years, 97.9% male, left ventricular ejection fraction: 34.8 ± 10.4%, 87.7% ischemic cardiomyopathy) were included. Postablation LGE-CMR showed a decrease in the number (3.34 ± 1.03 vs. 1.6 ± 0.2; p < 0.0001) and mass (8.45 ± 1.3 vs. 3.5 ± 0.6 grams; p < 0.001) of CCs. Arrhythmogenic CCs disappeared in 74.4% of patients. Dark core was detected in 75.5% of patients and its presence was not related to CCs reduction (52.2 ± 7.4% vs. 40.8 ± 10.6%, p = 0.57). VT recurrence after one year follow-up was 16.3%. The presence of 2 or more channels in the post-ablation LGE-CMR was a predictor of VT recurrence (31.82% vs 0%, p = 0.0038) with a sensibility of 100% and specificity of 61% (area under the curve 0.82). In the same line, a reduction of CCs less than 55% had sensibility of 100% and specificity of 61% (area under the curve 0.83) to predict VT recurrence.<br /><b>Conclusions</b><br />Postablation LGE-CMR is feasible, and a reduction in the number of CCs is related with lower risk of VT recurrence. The dark core was not present in all patients. A decrease in VT substrate was also observed in patients without dark core area in the postablation LGE-CMR.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 11 Oct 2023; epub ahead of print</small></div>

<div><h4>Prognostic Implications of the Extent of Cardiac Damage in Patients With Fabry Disease.</h4><i>Meucci MC, Lillo R, Del Franco A, Monda E, ... Olivotto I, Graziani F</i><br /><b>Background</b><br />There is limited evidence on the risk stratification of cardiovascular outcomes in patients with Fabry disease (FD).<br /><b>Objectives</b><br />This study sought to classify FD patients into disease stages, based on the extent of the cardiac damage evaluated by echocardiography, and to assess their prognostic impact in a multicenter cohort.<br /><b>Methods</b><br />Patients with FD from 5 Italian referral centers were categorized into 4 stages: stage 0, no cardiac involvement; stage 1, left ventricular (LV) hypertrophy (LV maximal wall thickness >12 mm); stage 2, left atrium (LA) enlargement (LA volume index >34 mL/m<sup>2</sup>); stage 3, ventricular impairment (LV ejection fraction <50% or E/e\' ≥15 or TAPSE <17 mm). The study endpoint was the composite of all-cause death, hospitalization for heart failure, new-onset atrial fibrillation, major bradyarrhythmias or tachyarrhythmias, and ischemic stroke.<br /><b>Results</b><br />A total of 314 patients were included. Among them, 174 (56%) were classified as stage 0, 41 (13%) as stage 1, 57 (18%) as stage 2 and 42 (13%) as stage 3. A progressive increase in the composite event rate at 8 years was observed with worsening stages of cardiac damage (log-rank P < 0.001). On multivariable Cox regression analysis, the staging was independently associated with the risk of cardiovascular events (HR: 2.086 per 1-stage increase; 95% CI: 1.487-2.927; P < 0.001). Notably, cardiac staging demonstrated a stronger and additive prognostic value, as compared with the degree of LV hypertrophy.<br /><b>Conclusions</b><br />In FD patients, a novel staging classification of cardiac damage, evaluated by echocardiography, is strongly associated with cardiovascular outcomes and may be helpful to refine risk stratification.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Coll Cardiol: 10 Oct 2023; 82:1524-1534</small></div>

<div><h4>Left atrial appendage closure in very elderly patients in the French National Registry.</h4><i>Teiger E, Eschalier R, Amabile N, Rioufol G, ... Le Corvoisier P, French Left Atrial Appendage Closure-2 registry (FLAAC-2) investigators</i><br /><b>Objective</b><br />Left atrial appendage closure (LAAC) is recommended to decrease the stroke risk in patients with atrial fibrillation and contraindications to anticoagulation. However, age-stratified data are scarce. The aim of this study was to provide information on the safety and efficacy of LAAC, with emphasis on the oldest patients.<br /><b>Methods</b><br />A nationwide, prospective, multicentre, observational registry was established by 53 French cardiology centres in 2018-2021. The composite primary endpoint included ischaemic stroke, systemic embolism, and unexplained or cardiovascular death. Separate analyses were done in the groups <80 years and ≥80 years.<br /><b>Results</b><br />Among the 1053 patients included, median age was 79.7 (73.6-84.3) years; 512 patients (48.6%) were aged ≥80 years. Procedure-related serious adverse events were non-significantly more common in octogenarians (7.0% vs 4.4% in patients aged <80 years, respectively; p=0.07). Despite a higher mean CHA<sub>2</sub>DS<sub>2</sub>-VASc score in octogenarians, the rate of thromboembolic events during the study was similar in both groups (3.0 vs 3.1/100 patient-years; p=0.85). By contrast, all-cause mortality was significantly higher in octogenarians (15.3 vs 10.1/100 patient-years, p<0.015), due to a higher rate of non-cardiovascular deaths (8.2 vs 4.9/100 patient-years, p=0.034). The rate of the primary endpoint was 8.1/100 patient-years overall with no statistically significant difference between age groups (9.4 and 7.0/100 patient-years; p=0.19).<br /><b>Conclusion</b><br />Despite a higher mean CHA<sub>2</sub>DS<sub>2</sub>-VASc score in octogenarians, the rate of thromboembolic events after LAAC in this age group was similar to that in patients aged <80 years.<br /><b>Trial registration number</b><br />ClinicalTrials.gov Registry (NCT03434015).<br /><br />© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.<br /><br /><small>Heart: 09 Oct 2023; epub ahead of print</small></div>

<div><h4>Impact of symptom-to-reperfusion-time on transmural infarct extent and left ventricular strain in patients with ST-segment elevation myocardial infarction: a 3-dimensional view on the wavefront phenomenon.</h4><i>Demirkiran A, Beijnink C, Kloner RA, Hopman LHGA, ... Robbers LFHJ, Nijveldt R</i><br /><b>Aims</b><br />We examined the association between the symptom-to-reperfusion-time and cardiovascular magnetic resonance (CMR)-derived global strain parameters and transmural infarct extent in ST-segment elevation myocardial infarction (STEMI) patients.<br /><b>Methods and results</b><br />The study included 108 STEMI patients who underwent successful primary percutaneous coronary intervention (PPCI). Patients were categorized according to the median symptom-to-reperfusion-time: shorter (<160 min, n = 54) and longer times (>160 min, n = 54). CMR was performed 2-7 days after PPCI and at 1-month. CMR cine imaging was performed for functional assessment and late gadolinium enhancement to evaluate transmural infarct extent. Myocardial feature-tracking was used for strain analysis. Groups were comparable in relation to incidence of LAD disease and pre and post-PPCI TIMI flow grades. The mean transmural extent score at follow-up was lower in patients with shorter reperfusion time (p < 0.01). Both baseline and follow-up maximum transmural extent scores were smaller in patients with shorter reperfusion time (p = 0.03 for both). Patients with shorter reperfusion time had more favorable global left ventricular (LV) circumferential strain (baseline, p = 0.049; follow-up, p = 0.01) and radial strain (baseline, p = 0.047; follow-up, p < 0.01), while LV longitudinal strain appeared comparable for both baseline and follow-up (p > 0.05 for both). In multivariable regression analysis including all 3 strain directions, baseline LV circumferential strain was independently associated with the mean transmural extent score at follow-up (β=1.89, p < 0.001).<br /><b>Conclusion</b><br />In STEMI patients, time-to-reperfusion was significantly associated with smaller transmural extent of infarction and better LV circumferential and radial strain. Moreover, infarct transmurality and residual LV circumferential strain are closely linked.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 09 Oct 2023; epub ahead of print</small></div>

<div><h4>Left Atrial Stiffness Index as a Predictor of Effort Intolerance and Hemodynamics Evaluated by Invasive Exercise Stress Testing in Degenerative Mitral Regurgitation.</h4><i>Takahari K, Susawa H, Utsunomiya H, Tsuchiya A, ... Itakura K, Nakano Y</i><br /><AbstractText>In patients with degenerative mitral regurgitation (DMR), peak oxygen consumption is the significant prognostic factor, and exercise intolerance has been considered a trigger for surgical intervention. The significant mitral regurgitation (MR) induces left atrial (LA) remodeling, but the significance of LA stiffness calculated by the ratio of E/e\' to LA reservoir strain in degenerative MR has not been elucidated. A total of 30 patients with asymptomatic or minimally symptomatic grade ≥III + DMR underwent the cardiopulmonary exercising test simultaneously with invasive hemodynamic assessment. LA stiffness index significantly correlated with exercise hemodynamic deterioration, including pulmonary arterial wedge pressure (r = 0.71, p <0.01), systolic pulmonary arterial pressure at peak exercise (r = 0.73, p <0.01), and pulmonary circulatory reserve (mean pulmonary arterial pressure/cardiac output slope, r = 0.45, p = 0.012). Multiple linear regression analysis revealed that the higher LA stiffness index was significantly associated with decreased percent predicted peak oxygen consumption (per 0.1 increase, β -4.0, 95% confidence interval -6.9 to -1.3, p <0.01) independently of MR deterioration during exercise. In conclusion, increased LA stiffness was associated with exercise intolerance through hemodynamic deterioration during exercise in patients with asymptomatic or minimally symptomatic severe DMR.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 07 Oct 2023; 208:65-71</small></div>

<div><h4>Multicenter Evaluation of the Feasibility of Clinical Implementation of SPECT Myocardial Blood Flow Measurement: Intersite Variability and Imaging Time.</h4><i>Wells RG, Bengel FM, Camoni L, Cerudelli E, ... Teng XF, Ruddy TD</i><br /><b>Background</b><br />Single-center studies have shown that single photon emission computed tomography myocardial blood flow (MBF) measurement is accurate compared with MBF measured with microspheres in a porcine model, positron emission tomography, and angiography. Clinical implementation requires consistency across multiple sites. The study goal is to determine the intersite processing repeatability of single photon emission computed tomography MBF and the additional camera time required.<br /><b>Methods</b><br />Five sites (Canada, Italy, Japan, Germany, and Singapore) each acquired 25 to 35 MBF studies at rest and with pharmacological stress using technetium-99m-tetrofosmin on a pinhole-collimated cadmium-zinc-telluride-based cardiac single photon emission computed tomography camera with standardized list-mode imaging and processing protocols. Patients had intermediate to high pretest probability of coronary artery disease. MBF was measured locally and at a core laboratory using commercially available software. The time a room was occupied for an MBF study was compared with that for a standard rest/stress myocardial perfusion study.<br /><b>Results</b><br />With motion correction, the overall correlation in MBF between core laboratory and local site was 0.93 (range, 0.87-0.97) at rest, 0.90 (range, 0.84-0.96) at stress, and 0.84 (range, 0.70-0.92) for myocardial flow reserve. The local-to-core difference in global MBF (bias<sub>-MBF</sub>) was 5.4% (-3.8% to 14.8%; median [interquartile range]) at rest and 5.4% (-6.2% to 19.4%) at stress. Between the 5 sites, bias<sub>-MBF</sub> ranged from -1.6% to 11.0% at rest and from -1.9% to 16.3% at stress; the interquartile range in bias<sub>-MBF</sub> was between 9.3% (4.8%-14.0%) and 22.3% (-10.3% to 12.0%) at rest and between 17.0% (-11.3% to 5.6%) and 33.3% (-10.4% to 22.9%) at stress and was not significantly different between most sites. Both bias and interquartile range were like previously reported interobserver variability and less than the SD of the test-retest difference of 30%. The overall difference in myocardial flow reserve was 1.52% (-10.6% to 11.3%). There were no significant differences between with and without motion correction. The average additional acquisition time varied between sites from 44 to 79 minutes.<br /><b>Conclusions</b><br />The average bias<sub>-MBF</sub> and bias<sub>-MFR</sub> values were small with standard deviations substantially less than the test-retest variability. This demonstrates that MBF can be measured consistently across multiple sites and further supports that this technique can be reliably implemented.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT03427749.<br /><br /><br /><br /><small>Circ Cardiovasc Imaging: 06 Oct 2023:e015009; epub ahead of print</small></div>

<div><h4>Atrial Myopathy Quantified by Speckle-Tracking Echocardiography in Mice.</h4><i>Zhang MJ, Gyberg DJ, Healy CL, Zhang N, ... Dudley SC, O\'Connell TD</i><br /><b>Background</b><br />Emerging evidence suggests that atrial myopathy may be the underlying pathophysiology that explains adverse cardiovascular outcomes in heart failure (HF) and atrial fibrillation. Lower left atrial (LA) function (strain) is a key biomarker of atrial myopathy, but murine LA strain has not been described, thus limiting translational investigation. Therefore, the objective of this study was to characterize LA function by speckle-tracking echocardiography in mouse models of atrial myopathy.<br /><b>Methods</b><br />We used 3 models of atrial myopathy in wild-type male and female C57Bl6/J mice: (1) aged 16 to 17 months, (2) Ang II (angiotensin II) infusion, and (3) high-fat diet+Nω-nitro-<sub>L</sub>-arginine methyl ester (HF with preserved ejection fraction, HFpEF). LA reservoir, conduit, and contractile strain were measured using speckle-tracking echocardiography from a modified parasternal long-axis window. Left ventricular systolic and diastolic function, and global longitudinal strain were also measured. Transesophageal rapid atrial pacing was used to induce atrial fibrillation.<br /><b>Results</b><br />LA reservoir, conduit, and contractile strain were significantly reduced in aged, Ang II and HFpEF mice compared with young controls. There were no sex-based interactions. Left ventricular diastolic function and global longitudinal strain were lower in aged, Ang II and HFpEF, but left ventricular ejection fraction was unchanged. Atrial fibrillation inducibility was low in young mice (5%), moderately higher in aged mice (20%), and high in Ang II (75%) and HFpEF (83%) mice.<br /><b>Conclusions</b><br />Using speckle-tracking echocardiography, we observed reduced LA function in established mouse models of atrial myopathy with concurrent atrial fibrillation inducibility, thus providing the field with a timely and clinically relevant platform for understanding the pathophysiology and discovery of novel treatment targets for atrial myopathy.<br /><br /><br /><br /><small>Circ Cardiovasc Imaging: 05 Oct 2023:e015735; epub ahead of print</small></div>

<div><h4>The Clinical use of Stress Echocardiography in Chronic Coronary Syndromes and Beyond Coronary artery disease: A Clinical Consensus Statement from the European Association of Cardiovascular Imaging of the ESC.</h4><i>Picano E, Pierard L, Peteiro J, Djordjevic-Dikic A, ... Neskovic AN, Henein M</i><br /><AbstractText>Since the 2009 publication of the stress echocardiography expert consensus of the European Association of Echocardiography, and after the 2016 advice of the American Society of Echocardiography-European Association of Cardiovascular Imaging for applications beyond coronary artery disease, new information has become available regarding stress echo. Until recently, the assessment of regional wall motion abnormality was the only universally practiced step of stress echo. In the state-of-the-art ABCDE protocol, regional wall motion abnormality remains the main step A, but at the same time, regional perfusion using ultrasound-contrast agents may be assessed. Diastolic function and pulmonary B-lines are assessed in step B; left ventricular contractile and preload reserve with volumetric echocardiography in step C; Doppler-based coronary flow velocity reserve in the left anterior descending coronary artery in step D; and ECG-based heart rate reserve in non-imaging step E. These five biomarkers converge, conceptually and methodologically, in the ABCDE protocol allowing comprehensive risk stratification of the vulnerable patient with chronic coronary syndromes. The present document summarizes current practice guidelines recommendations and training requirements and harmonizes the clinical guidelines of the European Society of Cardiology in many diverse cardiac conditions, from chronic coronary syndromes to valvular heart disease. The continuous refinement of imaging technology and the diffusion of ultrasound-contrast agents improve image quality, feasibility, and reader accuracy in assessing wall motion and perfusion, left ventricular volumes, and coronary flow velocity. Carotid imaging detects pre-obstructive atherosclerosis and improves risk prediction similarly to coronary atherosclerosis. The revolutionary impact of artificial intelligence on echocardiographic image acquisition and analysis makes stress echo more operator-independent and objective. Stress echo has unique features of low cost, versatility, and universal availability. It does not need ionizing radiation exposure and has near-zero carbon dioxide emissions. Stress echo is a convenient and sustainable choice for functional testing within and beyond coronary artery disease.</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 05 Oct 2023; epub ahead of print</small></div>

<div><h4>Strain assessment in aortic stenosis: pathophysiology and clinical utility.</h4><i>Meredith T, Roy D, Hayward C, Feneley M, ... Muller D, Namasivayam M</i><br /><AbstractText>Contemporary echocardiographic criteria for grading aortic stenosis severity have remained relatively unchanged despite significant advances in non-invasive imaging techniques over the last two decades. More recently, attention has shifted to the ventricular response to aortic stenosis and how this might be quantified. Global longitudinal strain (GLS), semi-automatically calculated from standard 2D echocardiographic images, has been the focus of extensive research. GLS is a sensitive marker of subtle hypertrophy-related impairment in left ventricular function and has shown promise as a relatively robust prognostic marker, both independently and when added to severity classification systems. Herein we review the pathophysiological basis underpinning the potential utility of GLS in the assessment of aortic stenosis, as well as its potential role in quantifying myocardial recovery and prognostic discrimination following aortic valve replacement.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 05 Oct 2023; epub ahead of print</small></div>

<div><h4>Misclassification of Females and Males in Cardiovascular Magnetic Resonance Parametric Mapping - The Importance of Sex-Specific Normal Ranges for Diagnosis of Health versus Disease.</h4><i>Thomas KE, Lukaschuk E, Shanmuganathan M, Kitt JA, ... Piechnik SK, Ferreira VM</i><br /><b>Aims</b><br />Cardiovascular magnetic resonance parametric mapping enables non-invasive quantitative myocardial tissue characterisation. Human myocardium has normal ranges of T1- and T2-values, deviation from which may indicate disease or change in physiology. Normal myocardial T1- and T2-values are affected by biological sex. Consequently, normal ranges created with insufficient numbers of each sex may result in sampling biases, misclassification of healthy values versus disease, and even misdiagnoses. We investigated the impact of using male normal ranges for classifying female cases as normal or abnormal (and vice versa).<br /><b>Methods and results</b><br />142 healthy volunteers (male and female) were scanned on two Siemens 3 T MR systems, providing averaged global myocardial T1- and T2-values on a per-subject basis. The Monte Carlo method was used to generate simulated normal ranges from these values, to estimate the statistical accuracy of classifying healthy female or male cases correctly as \'normal\' when using sex-specific versus mixed-sex normal ranges. Normal male and female T1- and T2-mapping values were significantly different by sex, after adjusting for age and heart rate.<br /><b>Conclusion</b><br />Using 15 healthy volunteers which are not sex-specific to establish a normal range typically misclassified up to 36% of healthy females and 37% of healthy males as having abnormal T1-values, and up to 16% of healthy females and 12% of healthy males as having abnormal T2-values. This paper highlights the potential adverse impact on diagnostic accuracy that can occur when local normal ranges contain insufficient numbers of both sexes. Sex-specific reference ranges should thus be routinely adopted into clinical practice.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 04 Oct 2023; epub ahead of print</small></div>

<div><h4>Impact of chronic obstructive pulmonary disease on right ventricular function and remodeling after aortic valve replacement.</h4><i>Myagmardorj R, Stassen J, Nabeta T, Hirasawa K, ... Delgado V, Bax JJ</i><br /><b>Background</b><br />Both chronic obstructive pulmonary disease (COPD) and right ventricular (RV) dysfunction are common factors that have been associated with poor prognosis after aortic valve replacement (AVR). Since there is still uncertainty about the impact of COPD on RV function and dilatation in patients undergoing AVR, we sought to explore RV function and remodeling in the presence and absence of COPD as well as their prognostic implications.<br /><b>Methods</b><br />Patients who received surgical or transcatheter AVR due to severe AS were screened for COPD. Demographic and clinical data were collected at baseline while echocardiographic measurements were performed at baseline and 1 year after AVR. The study end-point was all-cause mortality.<br /><b>Results</b><br />In total 275 patients were included, with 90 (33%) patients having COPD. At 1-year follow-up, mild worsening of tricuspid annular planar systolic excursion and RV dilatation were observed in patients without COPD, while there were significant improvements in RV longitudinal strain, RV wall thickness but dilatation of RV outflow tract distal dimension in the COPD group compared to the baseline. On multivariable analysis, the presence of COPD provided significant incremental prognostic value over RV dysfunction and remodeling.<br /><b>Conclusions</b><br />At 1-year after AVR, RV function and dimensions mildly deteriorated in non-COPD group whereas COPD group received significant benefit of AVR in terms of RV function and hypertrophy. COPD was independently associated with >2-fold all-cause mortality and had incremental prognostic value over RV dysfunction and remodeling.<br /><br />Copyright © 2023. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 04 Oct 2023:131414; epub ahead of print</small></div>

<div><h4>Midterm follow-up after computed tomography angiography planned left atrial appendage closure.</h4><i>Rana MA, Yoon S, Dallan LAP, Tashtish N, ... Arruda M, Filby SJ</i><br /><b>Background</b><br />While studies have shown the advantages of computed tomography angiography (CTA) over transesophageal echocardiography (TEE) in left atrial appendage closure (LAAC) preprocedural planning for WATCHMAN™ legacy and FLX devices, there has been no reported long-term data for this approach.<br /><b>Objectives</b><br />We sought to evaluate long-term outcomes using CTA-based preprocedural planning for LAAC using the WATCHMAN™ device.<br /><b>Methods</b><br />A prospective analysis of 231 consecutive patients who underwent LAAC in a single, large academic hospital in the United States was conducted over a 5-year period. CTA-guided preprocedural planning was performed in all. Procedural success, adverse events, length of procedure, number of devices used, and length of stay were evaluated. Rates of death, cerebral embolism, systemic embolism, and major and minor bleeding were recorded. Adjusted predicted stroke and major bleeding rates were derived from CHA2DS2-Vasc and HAS-BLED scores, respectively.<br /><b>Results</b><br />From January 26, 2017, to November 23, 2021, 231 patients underwent LAAC with CTA preprocedural planning by two operating physicians. The mean age of patients was 76.5 ± 8.4. 59.7% of patients were male. Mean CHA2DS2VASc and HAS-BLED scores were 4.5 ± 1.4 and 3.9 ± 0.9, respectively. All procedures were performed with intracardiac echo (100%). The procedural success rate was 99.1%. The CTA sizing strategy accurately predicted the implant size in 93.5% of patients. Mean number of devices used was 1.10 ± 0.3. Peri-procedural complication rate was 2.2%. 6 patients were lost to follow-up. Mean follow-up was 608.94 days with a total of 377.04 patient years. Median follow-up period of 368 days (interquartile range: 209-1067 days). There were 51 deaths from all causes (13.52 per 100 patient-years), 10 cases of cerebral embolism (2.65 per 100 patient-years), 2 cases of systemic embolism (0.53 per 100 patient-years), 17 cases of major bleeding (4.50 per 100 patient-years), and 31 cases of minor bleeding (8.2 per 100 patient-years). All-cause mortality at 1, 2, and 3 years was 12.7%, 20.9%, and 29.2%, respectively. CV event rates at 1, 2, and 3 years were 2.1%, 6.6%, and 10.5%, respectively.<br /><b>Conclusions</b><br />CTA-based preprocedural planning is accurate in predicting device size for LAAC and associated with excellent clinical outcomes at 5 years.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Rb and [O]HO myocardial perfusion PET imaging: a prospective head to head comparison.</h4><i>Krakauer M, Ismail A, Talleruphuus U, Henriksen AC, ... Hovind P, Marner L</i><br /><b>Background</b><br /><sup>82</sup>Rb PET and [<sup>15</sup>O]H<sub>2</sub>O PET are both validated tracers for myocardical perfusion imaging but have not previously been compared clinically. During our site\'s transition from <sup>82</sup>Rb to [<sup>15</sup>O]H<sub>2</sub>O PET, we performed a head-to-head comparison in a mixed population with suspected ischemic heart disease.<br /><b>Methods</b><br />A total of 37 patients referred for perfusion imaging due to suspicion of coronary stenosis were examined with both <sup>82</sup>Rb and [<sup>15</sup>O]H<sub>2</sub>O PET on the same day in rest and during adenosine-induced stress. The exams were rated by two blinded readers as normal, regional ischemia, globally reduced myocardial perfusion, or myocardial scarring. For [<sup>15</sup>O]H<sub>2</sub>O PET, regional ischemia was defined as two neighboring segments with average stress perfusion ≤ 2.3 mL/(min·g). Further, we evaluated a total perfusion deficit (TPD) of ≥ 10% as a more conservative marker of ischemia.<br /><b>Results</b><br />[<sup>15</sup>O]H<sub>2</sub>O PET identified more patients with regional ischemia: 17(46%) vs 9(24%), agreement: 59% corresponding to a Cohen\'s kappa of .31 [95%CI .08-.53], (P < .001). Using the more conservative TPD ≥ 10%, the agreement increased to 86% corresponding to a kappa of .62 [95%CI .33-.92], (P = .001). For the subgroup of patients with no known heart disease (n = 18), the agreement was 94%. Interrater agreement was 95% corresponding to a kappa of .89 [95%CI .74-1.00] (P < .001).<br /><b>Conclusions</b><br />In clinical transition from <sup>82</sup>Rb to [<sup>15</sup>O]H<sub>2</sub>O PET, it is important to take into account the higher frequency of patients with regional ischemia detected by [<sup>15</sup>O]H<sub>2</sub>O PET.<br /><br />© 2023. The Author(s).<br /><br /><small>J Nucl Cardiol: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Quantitative assessment of angioplasty-induced vascular inflammation with F cardiovascular magnetic resonance imaging.</h4><i>Nienhaus F, Walz M, Rothe M, Jahn A, ... Kelm M, Bönner F</i><br /><b>Background</b><br />Macrophages play a pivotal role in vascular inflammation and predict cardiovascular complications. Fluorine-19 magnetic resonance imaging (<sup>19</sup>F MRI) with intravenously applied perfluorocarbon allows a background-free direct quantification of macrophage abundance in experimental vascular disease models in mice. Recently, perfluorooctyl bromide-nanoemulsion (PFOB-NE) was applied to effectively image macrophage infiltration in a pig model of myocardial infarction using clinical MRI scanners. In the present proof-of-concept approach, we aimed to non-invasively image monocyte/macrophage infiltration in response to carotid artery angioplasty in pigs using <sup>19</sup>F MRI to assess early inflammatory response to mechanical injury.<br /><b>Methods</b><br />In eight minipigs, two different types of vascular injury were conducted: a mild injury employing balloon oversize angioplasty only (BA, n = 4) and a severe injury provoked by BA in combination with endothelial denudation (BA + ECDN, n = 4). PFOB-NE was administered intravenously three days after injury followed by <sup>1</sup>H and <sup>19</sup>F MRI to assess vascular inflammatory burden at day six. Vascular response to mechanical injury was validated using X-ray angiography, intravascular ultrasound and immunohistology in at least 10 segments per carotid artery.<br /><b>Results</b><br />Angioplasty was successfully induced in all eight pigs. Response to injury was characterized by positive remodeling with predominantly adventitial wall thickening and concomitant infiltration of monocytes/macrophages. No severe adverse reactions were observed following PFOB-NE administration. In vivo <sup>19</sup>F signals were only detected in the four pigs following BA + ECDN with a robust signal-to-noise ratio (SNR) of 14.7 ± 4.8. Ex vivo analysis revealed a linear correlation of <sup>19</sup>F SNR to local monocyte/macrophage cell density. Minimum detection limit of infiltrated monocytes/macrophages was estimated at approximately 410 cells/mm<sup>2</sup>.<br /><b>Conclusions</b><br />In this proof-of-concept study, <sup>19</sup>F MRI enabled quantification of monocyte/macrophage infiltration after vascular injury with sufficient sensitivity. This may provide the opportunity to non-invasively monitor vascular inflammation with MRI in patients after angioplasty or even in atherosclerotic plaques.<br /><br />© 2023. Society for Cardiovascular Magnetic Resonance.<br /><br /><small>J Cardiovasc Magn Reson: 03 Oct 2023; 25:54</small></div>

<div><h4>Prevalence and Prognostic Importance of Abnormal Positron Emission Tomography Among Asymptomatic Patients With Diabetes Mellitus.</h4><i>Patel KK, Singh A, Peri-Okonny PA, Patel FS, ... Shaw LJ, Bateman TM</i><br /><b>Background</b><br />Ischemia and reduced global myocardial blood flow reserve (MBFR) are associated with high cardiovascular risk among symptomatic patients with diabetes mellitus (DM).<br /><b>Objectives</b><br />This study aimed to assess the prevalence and prognostic importance of silent ischemia and reduced MBFR among asymptomatic patients with DM.<br /><b>Methods</b><br />This study included 2,730 consecutive patients with DM, without known coronary artery disease (CAD) or cardiomyopathy, who underwent rubidium-82 rest/stress positron emission tomography myocardial perfusion imaging (PET MPI) from 2010 to 2016. These patients were followed up for all-cause mortality (n = 461) for a median follow-up of 3 years. Patients were considered asymptomatic if neither chest pain nor dyspnea was elicited. Rates of ischemia, reduced MBFR, and coronary microvascular dysfunction on PET were assessed in both groups. Cox regression was used to define the independent association of abnormal MPI markers with mortality.<br /><b>Results</b><br />One-quarter of patients with DM (23.7%; n = 647) were asymptomatic; ischemia was present in 30.5% (n = 197), reduced MBFR in 62.3% (n = 361), and coronary microvascular dysfunction in 32.7% (n = 200). In adjusted analyses, reduced MBFR (HR per 0.1 unit decrease in MBFR: 1.08 [95% CI: 1.03-1.12]; P = 0.001) and reduced ejection fraction (HR per 5% decrease: 1.10 [95% CI: 1.01-1.18]; P = 0.02) were independently prognostic of mortality among asymptomatic patients, but ischemia was not. This was comparable to DM patients with symptoms. Insulin use and older age were significant predictors of reduced MBFR among asymptomatic patients with DM.<br /><b>Conclusions</b><br />In both symptomatic and asymptomatic patients with DM, impairment in MBFR is common and associated with greater mortality risk.<br /><br />Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.<br /><br /><small>JACC Cardiovasc Imaging: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Integration of longitudinal and circumferential strain predicts volumetric change across the cardiac cycle and differentiates patients along the heart failure continuum.</h4><i>Samuel TJ, Oneglia AP, Cipher DJ, Ezekowitz JA, ... Thompson RB, Nelson MD</i><br /><b>Background</b><br />Left ventricular (LV) circumferential and longitudinal strain provide important insight into LV mechanics and function, each contributing to volumetric changes throughout the cardiac cycle. We sought to explore this strain-volume relationship in more detail, by mathematically integrating circumferential and longitudinal strain and strain rate to predict LV volume and volumetric rates of change.<br /><b>Methods</b><br />Cardiac magnetic resonance (CMR) imaging from 229 participants from the Alberta HEART Study (46 healthy controls, 77 individuals at risk for developing heart failure [HF], 70 patients with diagnosed HF with preserved ejection fraction [HFpEF], and 36 patients with diagnosed HF with reduced ejection fraction [HFrEF]) were evaluated. LV volume was assessed by the method of disks and strain/strain rate were assessed by CMR feature tracking.<br /><b>Results</b><br />Integrating endocardial circumferential and longitudinal strain provided a close approximation of LV ejection fraction (EF<sub>Strain</sub>), when compared to gold-standard volumetric assessment (EF<sub>Volume</sub>: r = 0.94, P < 0.0001). Likewise, integrating circumferential and longitudinal strain rate provided a close approximation of peak ejection and peak filling rates (PER<sub>Strain</sub> and PFR<sub>Strain</sub>, respectively) compared to their gold-standard volume-time equivalents (PER<sub>Volume</sub>, r = 0.73, P < 0.0001 and PFR<sub>Volume</sub>, r = 0.78, P < 0.0001, respectively). Moreover, each integrated strain measure differentiated patients across the HF continuum (all P < 0.01), with the HFrEF group having worse EF<sub>Strain</sub>, PER<sub>Strain</sub>, and PFR<sub>Strain</sub> compared to all other groups, and HFpEF having less favorable EF<sub>Strain</sub> and PFR<sub>Strain</sub> compared to both at-risk and control groups.<br /><b>Conclusions</b><br />The data herein establish the theoretical framework for integrating discrete strain components into volumetric measurements across the cardiac cycle, and highlight the potential benefit of this approach for differentiating patients along the heart failure continuum.<br /><br />© 2023. Society for Cardiovascular Magnetic Resonance.<br /><br /><small>J Cardiovasc Magn Reson: 02 Oct 2023; 25:55</small></div>

<div><h4>Automated detection of cardiac rest period for trigger delay calculation for image-based navigator coronary magnetic resonance angiography.</h4><i>Wood G, Pedersen AU, Kunze KP, Neji R, ... Botnar RM, Kim WY</i><br /><b>Background</b><br />Coronary magnetic resonance angiography (coronary MRA) is increasingly being considered as a clinically viable method to investigate coronary artery disease (CAD). Accurate determination of the trigger delay to place the acquisition window within the quiescent part of the cardiac cycle is critical for coronary MRA in order to reduce cardiac motion. This is currently reliant on operator-led decision making, which can negatively affect consistency of scan acquisition. Recently developed deep learning (DL) derived software may overcome these issues by automation of cardiac rest period detection.<br /><b>Methods</b><br />Thirty individuals (female, n = 10) were investigated using a 0.9 mm isotropic image-navigator (iNAV)-based motion-corrected coronary MRA sequence. Each individual was scanned three times utilising different strategies for determination of the optimal trigger delay: (1) the DL software, (2) an experienced operator decision, and (3) a previously utilised formula for determining the trigger delay. Methodologies were compared using custom-made analysis software to assess visible coronary vessel length and coronary vessel sharpness for the entire vessel length and the first 4 cm of each vessel.<br /><b>Results</b><br />There was no difference in image quality between any of the methodologies for determination of the optimal trigger delay, as assessed by visible coronary vessel length, coronary vessel sharpness for each entire vessel and vessel sharpness for the first 4 cm of the left mainstem, left anterior descending or right coronary arteries. However, vessel length of the left circumflex was slightly greater using the formula method. The time taken to calculate the trigger delay was significantly lower for the DL-method as compared to the operator-led approach (106 ± 38.0 s vs 168 ± 39.2 s, p < 0.01, 95% CI of difference 25.5-98.1 s).<br /><b>Conclusions</b><br />Deep learning-derived automated software can effectively and efficiently determine the optimal trigger delay for acquisition of coronary MRA and thus may simplify workflow and improve reproducibility.<br /><br />© 2023. Society for Cardiovascular Magnetic Resonance.<br /><br /><small>J Cardiovasc Magn Reson: 02 Oct 2023; 25:52</small></div>

<div><h4>Highly accelerated free-breathing real-time myocardial tagging for exercise cardiovascular magnetic resonance.</h4><i>Morales MA, Yoon S, Fahmy A, Ghanbari F, ... Manning WJ, Nezafat R</i><br /><b>Background</b><br />Exercise cardiovascular magnetic resonance (Ex-CMR) myocardial tagging would enable quantification of myocardial deformation after exercise. However, current electrocardiogram (ECG)-segmented sequences are limited for Ex-CMR.<br /><b>Methods</b><br />We developed a highly accelerated balanced steady-state free-precession real-time tagging technique for 3 T. A 12-fold acceleration was achieved using incoherent sixfold random Cartesian sampling, twofold truncated outer phase encoding, and a deep learning resolution enhancement model. The technique was tested in two prospective studies. In a rest study of 27 patients referred for clinical CMR and 19 healthy subjects, a set of ECG-segmented for comparison and two sets of real-time tagging images for repeatability assessment were collected in 2-chamber and short-axis views with spatiotemporal resolution 2.0 × 2.0 mm<sup>2</sup> and 29 ms. In an Ex-CMR study of 26 patients with known or suspected cardiac disease and 23 healthy subjects, real-time images were collected before and after exercise. Deformation was quantified using measures of short-axis global circumferential strain (GCS). Two experienced CMR readers evaluated the image quality of all real-time data pooled from both studies using a 4-point Likert scale for tagline quality (1-excellent; 2-good; 3-moderate; 4-poor) and artifact level (1-none; 2-minimal; 3-moderate; 4-significant). Statistical evaluation included Pearson correlation coefficient (r), intraclass correlation coefficient (ICC), and coefficient of variation (CoV).<br /><b>Results</b><br />In the rest study, deformation was successfully quantified in 90% of cases. There was a good correlation (r = 0.71) between ECG-segmented and real-time measures of GCS, and repeatability was good to excellent (ICC = 0.86 [0.71, 0.94]) with a CoV of 4.7%. In the Ex-CMR study, deformation was successfully quantified in 96% of subjects pre-exercise and 84% of subjects post-exercise. Short-axis and 2-chamber tagline quality were 1.6 ± 0.7 and 1.9 ± 0.8 at rest and 1.9 ± 0.7 and 2.5 ± 0.8 after exercise, respectively. Short-axis and 2-chamber artifact level was 1.2 ± 0.5 and 1.4 ± 0.7 at rest and 1.3 ± 0.6 and 1.5 ± 0.8 post-exercise, respectively.<br /><b>Conclusion</b><br />We developed a highly accelerated real-time tagging technique and demonstrated its potential for Ex-CMR quantification of myocardial deformation. Further studies are needed to assess the clinical utility of our technique.<br /><br />© 2023. Society for Cardiovascular Magnetic Resonance.<br /><br /><small>J Cardiovasc Magn Reson: 02 Oct 2023; 25:56</small></div>

<div><h4>Deep-learning-based methods of attenuation correction for SPECT and PET.</h4><i>Chen X, Liu C</i><br /><AbstractText>Attenuation correction (AC) is essential for quantitative analysis and clinical diagnosis of single-photon emission computed tomography (SPECT) and positron emission tomography (PET). In clinical practice, computed tomography (CT) is utilized to generate attenuation maps (μ-maps) for AC of hybrid SPECT/CT and PET/CT scanners. However, CT-based AC methods frequently produce artifacts due to CT artifacts and misregistration of SPECT-CT and PET-CT scans. Segmentation-based AC methods using magnetic resonance imaging (MRI) for PET/MRI scanners are inaccurate and complicated since MRI does not contain direct information of photon attenuation. Computational AC methods for SPECT and PET estimate attenuation coefficients directly from raw emission data, but suffer from low accuracy, cross-talk artifacts, high computational complexity, and high noise level. The recently evolving deep-learning-based methods have shown promising results in AC of SPECT and PET, which can be generally divided into two categories: indirect and direct strategies. Indirect AC strategies apply neural networks to transform emission, transmission, or MR images into synthetic μ-maps or CT images which are then incorporated into AC reconstruction. Direct AC strategies skip the intermediate steps of generating μ-maps or CT images and predict AC SPECT or PET images from non-attenuation-correction (NAC) SPECT or PET images directly. These deep-learning-based AC methods show comparable and even superior performance to non-deep-learning methods. In this article, we first discussed the principles and limitations of non-deep-learning AC methods, and then reviewed the status and prospects of deep-learning-based methods for AC of SPECT and PET.</AbstractText><br /><br />© 2022. The Author(s) under exclusive licence to American Society of Nuclear Cardiology.<br /><br /><small>J Nucl Cardiol: 01 Oct 2023; 30:1859-1878</small></div>