Topic: Imaging

Abstract

Outcome and durability of mitral valve annuloplasty in atrial secondary mitral regurgitation.

Deferm S, Bertrand PB, Verhaert D, Dauw J, ... Vandervoort PM, Rega F
Objectives
Atrial secondary mitral regurgitation (ASMR) is a clinically distinct form of Carpentier type I mitral regurgitation (MR), rooted in excessive atrial and mitral annular dilation in the absence of left ventricular dysfunction. Mitral valve annuloplasty (MVA) is expected to provide a more durable solution for ASMR than for ventricular secondary MR (VSMR). Yet data on MR recurrence and outcome after MVA for ASMR are scarce. This study sought to investigate surgical outcomes and repair durability in patients with ASMR, as compared with a contemporary group of patients with VSMR.
Methods
Clinical and echocardiographic data from consecutive patients who underwent MVA to treat ASMR or VSMR in an academic centre were retrospectively analysed. Patient characteristics, operative outcomes, time to recurrence of ≥moderate MR and all-cause mortality were compared between patients with ASMR versus VSMR.
Results
Of the 216 patients analysed, 97 had ASMR opposed to 119 with VSMR and subvalvular leaflet tethering. Patients with ASMR were typically female (68.0% vs 33.6% in VSMR, p<0.001), with a history of atrial fibrillation (76.3% vs 33.6% in VSMR, p<0.001), paralleling a larger left atrial size (p<0.033). At a median follow-up of 3.3 (IQR 1.0-7.3) years, recurrence of ≥moderate MR was significantly lower in ASMR versus VSMR (7% vs 25% at 2 years, overall log-rank p=0.001), also when accounting for all-cause death as competing risk (subdistribution HR 0.50 in ASMR, 95% CI 0.29 to 0.88, p=0.016). Moreover, ASMR was associated with better overall survival compared with VSMR (adjusted HR 0.43 95% CI 0.22 to 0.82, p=0.011), independent from baseline European System for Cardiac Operative Risk Evaluation II surgical risk score.
Conclusion
Prognosis following MVA to treat ASMR is better, compared with VSMR as reflected by lower all-cause mortality and MR recurrence. Early distinction of secondary MR towards underlying ventricular versus atrial disease has important therapeutic implications.

© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Aug 2021; 107:1503-1509
Deferm S, Bertrand PB, Verhaert D, Dauw J, ... Vandervoort PM, Rega F
Heart: 30 Aug 2021; 107:1503-1509 | PMID: 34415852
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Abstract

Independent Association of Fatty Liver Index With Left Ventricular Diastolic Dysfunction in Subjects Without Medication.

Furuhashi M, Muranaka A, Yuda S, Tanaka M, ... Shimamoto K, Miura T
Nonalcoholic fatty liver disease has been reported to be potentially linked to cardiovascular disease. Fatty liver index (FLI) is a noninvasive and simple predictor of nonalcoholic fatty liver disease. However, little is known about the relationship between FLI and cardiac function, especially in a general population. We investigated the relationships of FLI with echocardiographic parameters in 185 subjects (men/women: 79/106) of the Tanno-Sobetsu Study, a population-based cohort, who were not being treated with any medication and who underwent echocardiography. FLI was negatively correlated with high-density lipoprotein cholesterol and peak myocardial velocity during early diastole (e\'; r = -0.342, p <0.001), an index of left ventricular (LV) diastolic function, and ratio of peak mitral velocities during early and late diastole (E/A) and was positively correlated with age, systolic and diastolic blood pressures, creatinine, uric acid, homeostasis model assessment of insulin resistance, high-sensitivity C-reactive protein, ratio of mitral to myocardial early diastolic peak velocity (E/e\'), left atrial volume index and LV mass index. No significant correlation was found between FLI and LV ejection fraction. Stepwise multivariable regression analysis showed that FLI was independently and negatively associated with e\' after adjustment of age, gender, high-density lipoprotein cholesterol, homeostasis model assessment of insulin resistance, and high-sensitivity C-reactive protein. Conversely, e\' was independently and negatively associated with FLI after adjustment of age, gender, systolic blood pressure, and LV ejection fraction. In conclusion, elevated FLI is independently associated with LV diastolic dysfunction in a general population without medication. FLI would be a novel marker of LV diastolic dysfunction as an early sign of myocardial injury.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Aug 2021; epub ahead of print
Furuhashi M, Muranaka A, Yuda S, Tanaka M, ... Shimamoto K, Miura T
Am J Cardiol: 30 Aug 2021; epub ahead of print | PMID: 34474907
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Abstract

Analysis of Differences in Assessment of Left Ventricular Function on Echocardiography and Nuclear Perfusion Imaging.

Jacobson AF, Narula J, Tijssen J
Two widely used methods for left ventricular (LV) ejection fraction (EF) determination, echocardiography (echo) and gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), often have wide limits of agreement. Factors influencing discrepancies between core laboratory echo and MPI LVEF determinations were examined in a large series of heart failure (HF) subjects and normal controls. 879 HF and 101 control subjects had core lab analyses of echo and MPI (mean time between procedures 7-8 days). LVEF differences were analyzed using one-way analysis of variance and Bland-Altman plots. Relationships between LVEF differences and patient characteristics and outcome endpoints (mortality and arrhythmias) were explored with logistic regression, Cox proportional hazards models, and Kaplan-Meier survival analyses. There was a systematic difference between the 2 modalities; echo LVEF was higher with more severe LV dysfunction, MPI LVEF higher when systolic function was normal. LVEF results were within ±5% in only 37% of HF and 23% of control subjects. Considering discordance around the LVEF threshold 35%, there was disagreement between the 2 methods in 305 HF subjects (35%). Male gender (odds ratio (OR) = 0.200), atrial fibrillation (OR = 2.314), higher body mass index (OR = 1.051) and lower LV end-diastolic volume (OR = 0.985) were the strongest predictors of methodologic discordance. Cardiac event rates were highest if both LVEF values were ≤35% and lowest when both LVEF values were >35%. In conclusion, substantial disagreements between LVEF results by echo and MPI are common. HF patients with LVEF ≤35% by both techniques have the highest 2-year event risk.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2021; 156:85-92
Jacobson AF, Narula J, Tijssen J
Am J Cardiol: 30 Sep 2021; 156:85-92 | PMID: 34344513
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Abstract

Three-Dimensional Echocardiographic Left Atrial Appendage Volumetric Analysis.

Meltzer SN, Phatak PM, Fazlalizadeh H, Chang I, ... Kumar P, Medvedofsky D
Background
Left atrial appendage (LAA) echocardiographic assessment is difficult because of the complex shape and relatively small size of the LAA. Three-dimensional (3D) echocardiographic imaging can overcome the limitations of two-dimensional imaging. Pulsed-wave Doppler is the only currently standard LAA functional parameter. The aim of this study was to test a new approach for 3D echocardiographic volumetric analysis to obtain LAA ejection fraction (EF), its size and shape.
Methods
Transesophageal two-dimensional and 3D LAA images were prospectively obtained in 159 consecutive patients. LAA volumes were measured from 3D echocardiographic images using available software. Pulsed-wave Doppler was considered the reference value for LAA function and was used for comparison with LAA EF. Comparison with cardiac computed tomography was performed in a subgroup of 32 patients. Comparisons included linear regression and Bland-Altman analyses. Repeated measurements were performed to assess measurement variability.
Results
Nine patients were excluded because of suboptimal image quality (94% feasibility). Three-dimensional LAA calculated EF was in good agreement with LAA pulsed-wave measurements. Three-dimensional morphologic evaluation showed that 43% of the patients had \"chicken wing,\" 33% \"cactus,\" 19% \"windsock,\" and 5% cauliflower shapes. At the time of data acquisition, patients with atrial fibrillation had nonsignificantly larger LAA end-systolic and end-diastolic volumes, leading to lower calculated EFs. Three-dimensional echocardiographic LAA end-systolic volumes were in good agreement with cardiac computed tomography (r = 0.75), with small biases (mean, -2.5 ± 3.9 ml). Reproducibility was better for larger LAA volumes.
Conclusions
A novel 3D echocardiographic approach can determine the geometry, size, and function of the LAA. A new parameter, LAA EF, provides functional quantitation.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Aug 2021; 34:987-995
Meltzer SN, Phatak PM, Fazlalizadeh H, Chang I, ... Kumar P, Medvedofsky D
J Am Soc Echocardiogr: 30 Aug 2021; 34:987-995 | PMID: 33775733
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Abstract

The effect of cardiac rhythm on artificial intelligence-enabled ECG evaluation of left ventricular ejection fraction prediction in cardiac intensive care unit patients.

Kashou AH, Noseworthy PA, Lopez-Jimenez F, Attia ZI, ... Friedman PA, Jentzer JC
The presence of left ventricular systolic dysfunction (LVSD) alters clinical management and prognosis in most acute and chronic cardiovascular conditions. While transthoracic echocardiography (TTE) remains the most common diagnostic tool to screen for LVSD, it is operator-dependent, time-consuming, effort-intensive, and relatively expensive. Recent work has demonstrated the ability of an artificial intelligence-augment ECG (AI-ECG) model to accurately predict LVSD in critical intensive care unit (CICU) patients. We demonstrate that the AI-ECG algorithm can maintain its performance in these patients with and without AF despite their clinical differences. An AI-ECG algorithm can serve as a non-invasive, inexpensive, and rapid screening tool for early detection of LVSD in resource-limited settings, and potentially expedite clinical decision making and guideline-directed therapies in the acute care setting.

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

Int J Cardiol: 14 Sep 2021; 339:54-55
Kashou AH, Noseworthy PA, Lopez-Jimenez F, Attia ZI, ... Friedman PA, Jentzer JC
Int J Cardiol: 14 Sep 2021; 339:54-55 | PMID: 34242690
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Abstract

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

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

Copyright © 2021 Elsevier Ireland Ltd. All rights reserved.

Int J Cardiol: 01 Sep 2021; epub ahead of print
Rahman MU, Amritphale A, Kumar S, Trice C, Awan GM, Omar B
Int J Cardiol: 01 Sep 2021; epub ahead of print | PMID: 34481838
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Abstract

Additional diagnostic value of cardiac magnetic resonance feature tracking in patients with biopsy-proven arrhythmogenic cardiomyopathy.

Muscogiuri G, Fusini L, Ricci F, Sicuso R, ... Guaricci AI, Pontone G
Background
We aim to evaluate the value of Cardiac magnetic resonance (CMR) feature tracking (CMR-FT) in addition to Task Force Criteria(TFC) in patients with (arrhythmogenic cardiomyopathy) AC biopsy-proved.
Methods
Thirty-five patients with AC histologically proven who performed CMR with late gadolinium enhancement (LGE) acquisition were enrolled. The study population was divided in Group1 (negative CMR TFC and LV ejection fraction≥55%) and Group2 (positive CMR TFC and/or LVEF<55%) and compared to an age and gender-matched control group. CMR datasets of all patients were analyzed to calculate LV indexed end-diastolic (LVEDi) and end-systolic (LVESi) volumes and RV indexed end-diastolic (RVEDi) and end-systolic (RVESi) volumes, both LV ejection fraction (LVEF) and RV ejection fraction (RVEF). Moreover, LV and RV global longitudinal (GLS), circumferential (GCS) and radial (GRS) strain were measured.
Results
The AC patients showed both higher LVEDi (p:0.002) and RVEDi (p:0.017) and lower LVEF (p: 0.016) as compared to control patients. Moreover, AC patients showed impaired LV-GLS (p < 0.001), LV-GRS (p < 0.001), LV-GCS (p < 0.001) and RV-GRS (p:0.026) as compared to control subjects. Group1 patients showed a significant reduction of LV-GRS (p < 0.05) and LV-GCS p < 0.01) as compared to control subjects. At univariate analysis LV-GCS was the most discriminatory parameter between Group1 vs heathy subjects with an optimal cut-off of -15.8 (Sensitivity: 74%; Specificity: 10%).
Conclusions
In patients with AC biopsy-proven, CMR-FT could improve the diagnostic yield in the subset of patients who results negative for imaging TFC criteria resulting as useful gatekeeper for indication of myocardial biopsy in case of equivocal clinical and imaging presentation.

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

Int J Cardiol: 14 Sep 2021; 339:203-210
Muscogiuri G, Fusini L, Ricci F, Sicuso R, ... Guaricci AI, Pontone G
Int J Cardiol: 14 Sep 2021; 339:203-210 | PMID: 34242689
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Abstract

Left atrial phasic transport function closely correlates with fibrotic and arrhythmogenic atrial tissue degeneration in atrial fibrillation patients: cardiac magnetic resonance feature tracking and voltage mapping.

Schönbauer R, Tomala J, Kirstein B, Huo Y, ... Ulbrich S, Piorkowski C
Aims
To characterize the association of phasic left atrial (LA) transport function and LA fibrosis guided by multimodality imaging containing cardiac magnetic resonance imaging (CMR) feature tracking and bipolar voltage mapping.
Methods and results
Consecutive patients presenting for first-time ablation of atrial fibrillation (AF) were prospectively enrolled. Each patient underwent CMR prior to the ablation procedure. LA phasic indexed volumes (LA-Vi) and emptying fractions (LA-EF) were calculated and CMR feature tracking guided LA wall motion analysis was performed. LA bipolar voltage mapping was carried out in sinus rhythm to find areas of low voltage as a surrogate for fibrosis and arrhythmogenesis. One hundred and sixty-eight patients were enrolled. Low-voltage areas (LVAs) were present in 70 patients (42%). Contrary to LA volume, CMR based LA-EF [odds ratio (OR) 0.88, 95% confidence interval (CI) 0.80-0.96, P = 0.005] and LA booster pump strain rate (SR) (OR 0.98, 95% CI 0.97-0.99, P = 0.001) significantly predicted presence and extent of LVA in multivariate logistic regression analysis for patients scanned in SR. In receiver operating characteristic analysis, LA-EF <40% carried a sensitivity of 83% and specificity of 76% (area under the curve 0.8; 95% CI 0.71-0.89) to predict presence of LVA. For patients scanned in AF only minimal LA-Vi on CMR (OR: 1.06; 95% CI: 1.02-1.10; P = 0.002) predicted presence of LVA.
Conclusion
For patients scanned in SR LA-EF and LA booster pump SR are closely linked to the presence and extent of LA LVA.

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

Europace: 07 Sep 2021; 23:1400-1408
Schönbauer R, Tomala J, Kirstein B, Huo Y, ... Ulbrich S, Piorkowski C
Europace: 07 Sep 2021; 23:1400-1408 | PMID: 33693595
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Abstract

The usefulness of left ventricular volume and aortic diastolic flow reversal for grading chronic aortic regurgitation severity - Using cardiovascular magnetic resonance as reference.

Gao SA, Polte CL, Lagerstrand KM, Bech-Hanssen O
Echocardiographic evaluation of chronic aortic regurgitation (AR) severity can lead to diagnostic ambiguity due to few feasible parameters or incongruent findings. The aim of the present study was to improve the diagnostic usefulness of left ventricular (LV) enlargement and aortic end-diastolic flow velocity (EDFV) using cardiovascular magnetic resonance (CMR) as reference. Patients (n = 120) were recruited either prospectively (n = 45) or retrospectively (n = 75). Severe AR (CMR regurgitant fraction > 33%) was present in 51% and 93% of the patients had LV ejection fraction ≥ 50%. EDFV and LV end-diastolic volume index (EDVI) were assessed by echocardiography using the traditional (excluding trabeculae) and recommended approach (including trabeculae). The patients were randomised to a derivation (n = 60) or a test group (n = 60). EDVI (traditional/recommended) to rule in (>99/118 ml/m2) and rule out severe AR (≤75/87 ml/m2) were identified using ROC analyses in the derivation group. The corresponding thresholds for EDFV were >17 cm/s and ≤10 cm/s. In the test group, the positive/negative likelihood ratios to rule in/rule out severe AR using EDVI were 10.0/0.14 (traditional), 6.2/0.11 (recommended), and using EDFV were 10.2/0.08. To rule in and rule out severe AR using derived cut-off values instead of >2 SD reduced the false positives by 92%, whereas using EDFV ≤10 cm/s instead of ≤20 cm/s reduced the false negatives by 94%. In conclusion, EDVI and EDFV as quantitative parameters are useful to rule in or rule out severe chronic AR. Importantly, other causes of LV enlargement have to be considered.

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 29 Aug 2021; epub ahead of print
Gao SA, Polte CL, Lagerstrand KM, Bech-Hanssen O
Int J Cardiol: 29 Aug 2021; epub ahead of print | PMID: 34474096
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Abstract

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

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

Copyright © 2021. Published by Elsevier B.V.

Int J Cardiol: 25 Aug 2021; epub ahead of print
Harries I, Berlot B, Natasha ffrench-Constant, Williams M, ... Plana JC, Bucciarelli-Ducci C
Int J Cardiol: 25 Aug 2021; epub ahead of print | PMID: 34454967
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Abstract

ECG-based score estimates the probability to detect Fabry Disease cardiac involvement.

Figliozzi S, Camporeale A, Boveri S, Pieruzzi F, ... Namdar M, Lombardi M
Objectives
To elaborate an ECG-based nomogram estimating the probability to detect cardiac involvement by cardiac magnetic resonance (CMR) in Fabry Disease (FD).
Methods
119 FD patients and 26 healthy controls underwent ECG and CMR. Test (n = 88, 60%) and validation cohorts (n = 57, 40%) were randomly derived. Cardiac involvement was defined as the presence of low myocardial T1 value, a CMR-surrogate of myocardial glycosphingolipid storage. ECG changes associated with low T1 value were identified in the test cohort, included in the nomogram and then tested in the validation cohort.
Results
Sokolow-Lyon index (AUC = 0.769), ratio between P-wave and PR-segment durations (Pwave/PRsegment) (AUC = 0.778), QRS duration (AUC = 0.703), QT (AUC = 0.769) duration were independently associated with the presence of low T1 on CMR at multivariate analysis. An ECG-based nomogram including these four parameters was accurate in identifying patients with CMR evidence of glycosphingolipid storage (c-index of the derived-nomogram = 0.90 in the test group; 0.81 in the validation group).
Conclusion
We propose a practical ECG-based nomogram accurately estimating the probability to detect low T1 values by CMR in FD patients. The application of this tool in clinical practice could improve early detection of FD cardiac involvement.

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

Int J Cardiol: 14 Sep 2021; 339:110-117
Figliozzi S, Camporeale A, Boveri S, Pieruzzi F, ... Namdar M, Lombardi M
Int J Cardiol: 14 Sep 2021; 339:110-117 | PMID: 34274410
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Abstract

Impact of right ventricular systolic function in patients with significant tricuspid regurgitation. A cardiac magnetic resonance study.

Hinojar R, Gómez AG, García-Martin A, Monteagudo JM, ... Zamorano JL, Fernández-Golfín C
Background
Right ventricle (RV) dilatation and dysfunction are established criteria for intervention in severe tricuspid regurgitation (TR); however thresholds to support intervention are lacking. New measures of RV function such as RV shortening (RVS) and effective RV ejection fraction (eRVEF) may be earlier markers of RV dysfunction.
Purpose
to compare the prognostic impact of different parameters of RV function and to describe cut-off values of RV size/function and TR severity of poor prognosis.
Methods
Consecutive patients evaluated in the Heart Valve Clinic with significant TR (severe, massive or torrential TR) undergoing a CMR study were included. In addition to parameters of biventricular volume and function, RVS and eRVEF were assessed. A combined endpoint of hospital admission due to right heart failure and cardiovascular mortality was defined.
Results
75 patients were included (age 75 ± 8 years, female 75%). During a median follow-up of 3 years (IQR: 1.4-3.9 years), 39% experienced the endpoint. Cut-off values of worse prognosis were: RVS ≥ -14%, eRVEF ≤34%, RVEF ≤58%, RV-EDV ≥100 ml/m2, TR regurgitant fraction (TRF) ≥40% and TR volume ≥ 42 ml. RVS and eRVEF identified higher rates of RV dysfunction than RVEF. After adjustment for age and LVEF, both eRVEF ≤34% (HR: 5.29 [2.25-12.4]) and RVS ≥ -14% (HR: 3.46 [1.13-9.17]) were significantly associated with outcomes. Among all parameters of RV function, eRVEF was the strongest predictor of outcomes, incremental to RVEF (ΔC-statistic 0.139 [0.040-0.237], p = 0.005). Patients with eRVEF ≤34% and RV-EDV ≥100 ml/m2 or eRVEF ≤34% and TRF ≥40% had the worst prognosis (p < 0.01 for both).
Conclusion
RVS and eRVEF identify higher rates of RV dysfunction beyond RVEF. Among all measures, eRVEF held the strongest association with outcomes, incremental to RVEF.

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

Int J Cardiol: 14 Sep 2021; 339:120-127
Hinojar R, Gómez AG, García-Martin A, Monteagudo JM, ... Zamorano JL, Fernández-Golfín C
Int J Cardiol: 14 Sep 2021; 339:120-127 | PMID: 34273433
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Abstract

The effect of long-term left ventricular assist device support on flow-sensitive plasma microRNA levels.

Dlouha D, Ivak P, Netuka I, Novakova S, ... Hubacek JA, Pitha J
Background
Implantation of current generation left ventricular assist devices (LVADs) in the treatment of end-stage heart failure (HF), not only improves HF symptoms and end-organ perfusion, but also leads to cellular and molecular responses, presumably in response to the continuous flow generated by these devices. MicroRNAs (miRNAs) are important post-transcriptional regulators of gene expression in multiple biological processes, including the pathogenesis of HF. In our study, we examined the influence of long-term LVAD support on changes in flow-sensitive miRNAs in plasma.
Materials and methods
Blood samples from patients with end-stage heart failure (N = 33; age = 55.7 ± 11.6 years) were collected before LVAD implantation and 3, 6, 9, and 12 months after implantation. Plasma levels of the flow-sensitive miRNAs; miR-10a, miR-10b, miR-146a, miR-146b, miR-663a, miR-663b, miR-21, miR-155, and miR-126 were measured using quantitative PCR.
Results
Increasing quantities of miR-126 (P < 0.03) and miR-146a (P < 0.02) was observed at each follow-up visit after LVAD implantation. A positive association between miR-155 and Belcaro score (P < 0.04) and an inverse correlation between miR-126 and endothelial function, measured as the reactive hyperemia index (P < 0.05), was observed.
Conclusions
Our observations suggest that after LVAD implantation, low pulsatile flow up-regulates plasma levels of circulating flow-sensitive miRNAs, contributing to endothelial dysfunction and vascular remodeling.

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

Int J Cardiol: 14 Sep 2021; 339:138-143
Dlouha D, Ivak P, Netuka I, Novakova S, ... Hubacek JA, Pitha J
Int J Cardiol: 14 Sep 2021; 339:138-143 | PMID: 34197842
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Impact:
Abstract

Echocardiographic predictors of new-onset atrial arrhythmias in patients undergoing hematopoietic stem cell transplantation.

Singh N, Singh A, Besser SA, Lang RM, ... Bishop MR, DeCara JM
Background
Atrial arrhythmias following hematopoietic stem cell transplantation (HSCT) have been associated with increased length of stay, need for intensive care, and increased mortality within one-year post-transplant. We sought to identify echocardiographic parameters that may predict the development of new atrial arrhythmias post-HSCT.
Methods
We performed a retrospective chart review of 753 consecutive patients who underwent HSCT at the University of Chicago from January 2015 through December 2019. Patients with baseline echocardiogram within 6 months prior to transplantation were included. Those with prior transplants, history of atrial arrhythmias, or unavailable echocardiographic images were excluded, resulting in 187 patients included for final analysis. Baseline clinical and demographic variables, as well as echocardiographic parameters, were compared between patients who developed new atrial arrhythmias post-HSCT versus those who did not.
Results
Of the 187 patients included for analysis, 25 (13%) developed new atrial arrhythmias, with 13 of these occurring within 30 days of transplantation. Despite no significant difference in left atrial (LA) end-systolic volume between those with and without new arrhythmia following HSCT (OR 1.04; 95% CI 0.91-1.09, p = 0.233), univariable analysis demonstrated that patients who developed atrial arrhythmias had reduced LA function, as reflected by lower LA emptying fraction (OR 0.94; 95% CI 0.91-0.98, p = 0.003) and lower LA reservoir strain (OR 0.95; 95% CI 0.92-0.99, p = 0.009).
Conclusions
Echocardiographic indices of LA function, namely LA emptying fraction and LA reservoir strain, can identify patients at risk for developing new atrial arrhythmias post-HSCT, prior to the development of morphologic changes in the LA.

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

Int J Cardiol: 14 Sep 2021; 339:225-231
Singh N, Singh A, Besser SA, Lang RM, ... Bishop MR, DeCara JM
Int J Cardiol: 14 Sep 2021; 339:225-231 | PMID: 34174337
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Impact:
Abstract

Doppler mean gradient is discordant to aortic valve calcium scores in patients with atrial fibrillation undergoing transcatheter aortic valve replacement.

Alkurashi AK, Pislaru SV, Thaden JJ, Collins JD, ... Oh JK, Nkomo VT
Background
Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared to sinus rhythm (SR). Whether AS is more advanced at the time of referral to aortic valve intervention in AF compared to SR is unknown. The aim of this study was to examine flow-independent computed tomography aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR).
Methods
Patients who underwent TAVR from 2016-2020 for native valve severe AS with left ventricular ejection fraction ≥50% were identified from our institution TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared to AVCS (AVCS:MG ratio). AVCS were obtained within 90 days of the pre-TAVR echocardiogram.
Results
633 patients were included; age 82 years [76-86] and 46% were female. AF was present in 109/633 (17%) and SR 524/633 (83%) during the echocardiogram. Aortic valve area index was slightly smaller in AF versus SR (0.43; interquartile range [IQR] 0.39-0.47 vs 0.46 cm2/m2; IQR 0.41-0.51, p=0.0003). Stroke volume index, trans-aortic flow rate, and MG were lower in AF (p<0.0001 for all). The AVCS were higher in men with AF compared to SR (3510; IQR 2803-4030 vs 2722 AU; IQR 2180-3467, p <0.0001) in HGAS, but not in LGAS. The AVCS were not different in women with AF versus SR. Overall AVCS:MG ratios were higher in AF versus SR in HGAS and LGAS (p<0.03 for all), except in women with LGAS.
Conclusion
AVCS were higher than expected by MG in AF compared to SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 06 Sep 2021; epub ahead of print
Alkurashi AK, Pislaru SV, Thaden JJ, Collins JD, ... Oh JK, Nkomo VT
J Am Soc Echocardiogr: 06 Sep 2021; epub ahead of print | PMID: 34506919
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Impact:
Abstract

Cardiovascular implantable electronic device therapy in patients with left ventricular assist devices: insights from TRAViATA.

Darden D, Ammirati E, Brambatti M, Lin A, ... Adler E, Braun OÖ
Background
There is conflicting observational data on the survival benefit cardiac implantable electronic devices (CIED) in patients with LVADs.
Methods
Patients in whom an LVAD was implanted between January 2008 and April 2017 in the multinational Trans-Atlantic Registry on VAD and Transplant (TRAViATA) registry were separated into four groups based on the presence of CIED prior to LVAD implantation: none (n = 146), implantable cardiac defibrillator (ICD) (n = 239), cardiac resynchronization without defibrillator (CRT-P) (n = 28), and CRT with defibrillator (CRT-D) (n = 111).
Results
A total of 524 patients (age 52 years ±12, 84.4% male) were followed for 354 (interquartile range: 166-701) days. After multivariable adjustment, there were no differences in survival across the groups. In comparison to no device, only CRT-D was associated with late right ventricular failure (RVF) (hazard ratio 2.85, 95% confidence interval [CI] 1.42-5.72, p = 0.003). There was no difference in risk of early RVF across the groups or risk of ICD shocks between those with ICD and CRT-D.
Conclusion
In a multinational registry of patients with LVADs, there were no differences in survival with respect to CIED subtype. However, patients with a pre-existing CRT-D had a higher likelihood of late RVF suggesting significant long-term morbidity in those with devices capable of LV‑lead pacing post LVAD implantation.

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

Int J Cardiol: 22 Aug 2021; epub ahead of print
Darden D, Ammirati E, Brambatti M, Lin A, ... Adler E, Braun OÖ
Int J Cardiol: 22 Aug 2021; epub ahead of print | PMID: 34437934
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Impact:
Abstract

Left Atrial Strain Associated with Functional Recovery in Patients Receiving Optimal Treatment for Heart Failure.

Torii Y, Kusunose K, Hirata Y, Nishio S, ... Wakatsuki T, Sata M
Background
Heart failure with recovered ejection fraction (HFrecEF) has been reported in several previous studies to have a better prognosis than heart failure with reduced ejection fraction (HFrEF). However, the factors associated with HFrecEF have not been identified. The aim of this study was to test the hypothesis that left atrial (LA) strain could help identify patients with recovered ejection fraction (EF) among those with heart failure (HF) with low EF on admission.
Methods
One hundred consecutive patients hospitalized for the first time for new-onset HF were enrolled. Patients were clinically diagnosed with HFrEF on admission (left ventricular EF < 40%) and received optimal treatment for HF. Twenty-eight patients improved to HFrecEF during 6 months of follow-up.
Results
Regarding clinical background, there were significantly more women and a lower rate of atrial fibrillation in the HFrecEF group than in the HFrEF group. In a multivariate logistic regression analysis, LA strain was an independent predictor of HFrecEF, even after adjustment for gender and left ventricular EF (odds ratio: 4.06; 95% CI: 2.04-8.07; P < .001). A cutoff value of 10.8% for LA strain showed high sensitivity (96%) and specificity (82%) in identifying HFrecEF in patients with HF presenting with low EF on admission. During a follow-up period of 24 ± 13 months, 31 patients (31%) had cardiovascular death or readmission for HF. Patients with reduced LA strain (<10.8%) had significantly shorter event-free survival than those with preserved LA strain (P = .02).
Conclusions
LA strain is a useful indicator for predicting HFrecEF and should be considered as a routine measurement in patients with HFrEF on admission.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Aug 2021; 34:966-975.e2
Torii Y, Kusunose K, Hirata Y, Nishio S, ... Wakatsuki T, Sata M
J Am Soc Echocardiogr: 30 Aug 2021; 34:966-975.e2 | PMID: 33852960
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Impact:
Abstract

Left Atrial Strain and Function in Pediatric Hypertrophic Cardiomyopathy.

Jhaveri S, Komarlu R, Worley S, Shahbah D, Gurumoorthi M, Zahka K
Background
Left atrial (LA) strain and dysfunction are early markers of diastolic dysfunction, associated with poor exercise capacity in adults with hypertrophic cardiomyopathy (HCM). Literature on assessment of LA mechanics in pediatric HCM is lacking. The aim of this study was to assess LA strain and LA function in pediatric patients who have HCM with (phenotype positive [P+]) and without (genotype positive, phenotype negative [G+P-]) ventricular hypertrophy and evaluate their correlation with exercise stress test parameters.
Methods
Seventy-eight children (3-25 years of age) with HCM (P+, n = 46; G+P-, n = 32) and 20 healthy control subjects were retrospectively studied. LA conduit function, reservoir function, and pump function were computed using phasic LA volumetric analysis. LA reservoir strain (LASr) and LA contractile strain were measured using speckle-tracking echocardiography. Exercise test findings within 12 months of echocardiography were recorded.
Results
LA conduit function (36% vs 48%, P < .001) and LA reservoir function (137% vs 180%, P < .001) were lower in P+ than in G+P- patients. LA contractile function did not differ between the groups (31% vs 32%, P = .87). Compared with patients with G+P- HCM, those with P+HCM had lower four-chamber LASr (29% vs 41%, P < .001), two-chamber LASr (30% vs 41%, P < .001), average LASr (29% vs 42%, P < .001), and LA contractile strain (9% vs 12%, P = .016). In the cohort of patients with HCM who underwent stress testing (n = 35), LA conduit function weakly correlated with aerobic capacity (r = 0.42, P = .019).
Conclusions
Children with P+HCM have reduced LA function, measurable by both volumetric and strain analysis. Altered LA mechanics are associated with poor exercise capacity. This study lays the foundation for the evaluation of novel LA parameters in pediatric HCM and warrants larger longitudinal studies to assess its clinical significance.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Aug 2021; 34:996-1006
Jhaveri S, Komarlu R, Worley S, Shahbah D, Gurumoorthi M, Zahka K
J Am Soc Echocardiogr: 30 Aug 2021; 34:996-1006 | PMID: 33915246
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Impact:
Abstract

Prognostic Value of Peak Exercise Systolic Pulmonary Arterial Pressure in Asymptomatic Primary Mitral Valve Regurgitation.

Arangalage D, Cattan L, Eugène M, Cimadevilla C, ... Vahanian A, Messika-Zeitoun D
Background
The contribution of exercise echocardiography in primary asymptomatic mitral regurgitation (MR) remains debated. The aim of this study was to gain evidence regarding its usefulness in this setting and to investigate the prognostic value of peak exercise systolic pulmonary artery pressure (SPAP).
Methods
One hundred seventy-seven patients (mean age, 56 ± 13 years; 69% men) with moderate to severe (grade 3+) or severe (grade 4+) degenerative MR and preserved left ventricular ejection fraction, in sinus rhythm, referred for clinically indicated exercise echocardiography were identified. The end point, MR-related events, was a composite of all-cause death or occurrence of symptoms, heart failure, atrial fibrillation, left ventricular ejection fraction < 60%, left ventricular end-systolic diameter ≥ 45 mm, or resting SPAP > 50 mm Hg.
Results
At rest, effective regurgitant orifice area was 48 ± 16 mm2, regurgitant volume 74 ± 26 mL, and SPAP 32 ± 7 mm Hg, and MR was severe in 138 patients (78%). Peak exercise SPAP was 55 ± 10 mm Hg. Positive results on exercise testing motivated surgery in 26 patients, 11 underwent prophylactic surgery, 10 were lost to follow-up, and 130 were included in the outcome analysis. During a follow-up period of 19 ± 7 months, 31 MR-related events (24%) were reported. Peak exercise SPAP was predictive of outcomes in univariate analysis (P = .01) and after adjustment for age, gender, MR severity, and resting SPAP (P < .05). Peak exercise SPAP ≥ 50 mm Hg was associated with worse event-free survival (hazard ratio, 5.24; 95% CI, 1.77-15.53; P = .003), but not the threshold of ≥60 mm Hg proposed in previous guidelines (hazard ratio, 1.70; 95% CI, 0.71-4.03; P = .24).
Conclusions
The present findings support the use of exercise echocardiography for risk stratification in patients with asymptomatic primary MR and suggest a lower peak exercise SPAP threshold (50 mm Hg) than previously recommended to define the timing of intervention. Prospective studies are needed to confirm these findings.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Aug 2021; 34:932-940
Arangalage D, Cattan L, Eugène M, Cimadevilla C, ... Vahanian A, Messika-Zeitoun D
J Am Soc Echocardiogr: 30 Aug 2021; 34:932-940 | PMID: 33872700
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Impact:
Abstract

Feasibility and Accuracy of Automated Three-Dimensional Echocardiographic Analysis of Left Atrial Appendage for Transcatheter Closure.

Morais P, Fan Y, Queirós S, D\'hooge J, Pui-Wai Lee A, Vilaça JL
Background
Procedural success of transcatheter left atrial appendage closure (LAAC) is dependent on correct device selection. Three-dimensional transesophageal echocardiography (3D-TEE) is more accurate than the two-dimensional (2D) modality for evaluation of the complex anatomy of LAA. However, 3D-TEE analysis of LAA is challenging and highly expertise dependent. In this study, we sought to evaluate the feasibility and accuracy of a novel software tool for automated 3D analysis of the LAA using 3D-TEE data.
Methods
The intra-procedural 3D TEE data of 158 patients who underwent LAAC were retrospectively analyzed with a novel automated LAA analysis software tool. Based on the 3D TEE data, the software semi-automatically segmented the 3D LAA structure, determined the device landing zone (LZ), and generated measurements of the LZ dimensions and the LAA length, allowing manual editing if necessary. The accuracy of LAA pre-implantation anatomic measurement reproducibility, and time for analysis of the automated software were compared against expert manual 3D analysis. The software feasibility to predict the optimal device size was directly compared to implanted models.
Results
Automated 3D analysis of the LAA on 3D-TEE was feasible in all patients. There were excellent agreements between automated and manual measurements of LZ maximal diameter (bias:-0.32, LOA:-3.56; 2.92), area-derived mean diameter (bias:-0.24, LOA:-3.12, 2.64), and LAA depth (bias:0.02, LOA:-3.14; 3.18). Automated 3D analysis, with manual editing if necessary, accurately identified the implanted device size in 90.5% of patients, outperforming 2D-TEE (68.9%, p<0.01). The automated software showed results competitive against the manual analysis of 3D-TEE with higher intra- and inter-observer reproducibility and allowed quicker analysis (101.9±9.3s vs. 183.5±42.7s, p<0.001) compared to manual analysis.
Conclusions
Automated LAA analysis based on 3D-TEE is feasible and allows accurate, reproducible and rapid device sizing decision for LAAC.

Copyright © 2021. Published by Elsevier Inc.

J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print
Morais P, Fan Y, Queirós S, D'hooge J, Pui-Wai Lee A, Vilaça JL
J Am Soc Echocardiogr: 07 Sep 2021; epub ahead of print | PMID: 34508840
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Impact:
Abstract

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

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

Copyright © 2018. Published by Elsevier B.V.

Int J Cardiol: 13 Sep 2021; epub ahead of print
Wang X, Bai L, Liu X, Shen W, ... Liu W, Yu B
Int J Cardiol: 13 Sep 2021; epub ahead of print | PMID: 34534604
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Impact:
Abstract

Efficacy and safety of cardiac shock wave therapy for patients with severe coronary artery disease: A randomized, double-blind control study.

Jia N, Zhang R, Liu B, Liu B, ... Yao Z, He Q
Background
Previous studies proved the efficacy of cardiac shock wave therapy (CSWT) for coronary artery disease (CAD) patients who are not candidate for reperfusion therapy. Randomized control trials are limited. We try to explore the efficacy and safety of CSWT for patients with severe CAD.
Methods
Thirty patients with severe CAD who had obvious ischemia on myocardial perfusion imaging (MPI) were enrolled and randomly assigned to the CSWT group or the control group. They had received optimal medication treatment for at least three months. Nine sessions of shock wave therapy were conducted over 3 months. CSWT group received the real treatment, while the control group received the pseudo-treatment. Clinical symptom, imaging outcomes and safety parameters were compared between two groups.
Results
After treatment, regional stress score (P = .023), improvement rate (IR) of ischemic area (IA) stress (P < .001) and IR of IA difference (P < .001) were significantly favor CSWT group. The interaction of summed rest score (P < .001), summed stress score (P = .004), summed difference score (P = .036) were significantly improved in the CSWT group compared to the control group. Seattle angina questionnaire, quality of life (QOL) and the distance of six-minute walking test (6MWT) were improved in both groups without significant difference between them. Hemodynamic parameters were stable during procedure. Myocardial injury markers showed no changes in two groups.
Conclusions
Our study demonstrated CSWT could effectively and safely improve myocardial perfusion in patients with severe CAD. Clinical symptom, QOL and 6MWT were all improved after treatment, but no significant difference between two groups.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 01 Sep 2021; epub ahead of print
Jia N, Zhang R, Liu B, Liu B, ... Yao Z, He Q
J Nucl Cardiol: 01 Sep 2021; epub ahead of print | PMID: 34476776
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Impact:
Abstract

Combining body mass index with waist circumference to assess coronary microvascular function in patients with non-obstructive coronary artery disease.

Wang R, Li X, Huangfu S, Yao Q, ... Yan R, Li S
Background
Coronary microvascular dysfunction (CMD) may precede clinically overt coronary artery disease (CAD). Overall and central obesity (CO) are major risk factors for CAD. This study sought to investigate the subclinical significance of body adiposity patterns based on the CMD risk.
Methods
A total of 128 patients with non-obstructive CAD were prospectively enrolled. Patients were categorized into 4 anthropometric groups: normal weight and non-CO (NWNCO, n = 41), normal weight and CO (NWCO, n = 20), excess weight and non-CO (EWNCO, n = 26), and excess weight and CO (EWCO, n = 41). Patients underwent rest/stress electrocardiography-gated 13N-ammonia positron emission tomography to measure absolute myocardial blood flow (MBF), myocardial flow reserve (MFR), hemodynamic parameters, and cardiac function.
Results
Resting MBF did not differ between groups (P = .36). Compared with the NWNCO group, hyperemic MBF and MFR were significantly lower in the NWCO and EWCO groups. Notably, patients with NWCO presented the lowest hyperemic MBF and MFR and the highest incidence of CMD. Waist circumference was an independent risk factor for CMD (OR 1.05, 95% CI 1.01 to 1.10, P = .02).
Conclusion
In patients with non-obstructive CAD, CO may be associated with an increased risk of CMD to better fit the study findings which did not assess management or monitoring of MBF and MFR.

© 2021. The Author(s).

J Nucl Cardiol: 02 Sep 2021; epub ahead of print
Wang R, Li X, Huangfu S, Yao Q, ... Yan R, Li S
J Nucl Cardiol: 02 Sep 2021; epub ahead of print | PMID: 34476781
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Impact:
Abstract

Multimodality imaging to distinguish between benign and malignant cardiac masses.

Aghayev A, Cheezum MK, Steigner ML, Mousavi N, ... Di Carli MF, Blankstein R
Background
To compare the diagnostic accuracy of CMR and FDG-PET/CT and their complementary role to distinguish benign vs malignant cardiac masses.
Methods
Retrospectively assessed patients with cardiac mass who underwent CMR and FDG-PET/CT within a month between 2003 and 2018.
Results
72 patients who had CMR and FDG-PET/CT were included. 25 patients (35%) were diagnosed with benign and 47 (65%) were diagnosed with malignant masses. 56 patients had histological correlation: 9 benign and 47 malignant masses. CMR and FDG-PET/CT had a high accuracy in differentiating benign vs malignant masses, with the presence of CMR features demonstrating a higher sensitivity (98%), while FDG uptake with SUVmax/blood pool ≥ 3.0 demonstrating a high specificity (88%). Combining multiple (> 4) CMR features and FDG uptake (SUVmax/blood pool ratio ≥ 3.0) yielded a sensitivity of 85% and specificity of 88% to diagnose malignant masses. Over a mean follow-up of 2.6 years (IQR 0.3-3.8 years), risk-adjusted mortality were highest among patients with an infiltrative border on CMR (adjusted HR 3.1; 95% CI 1.5-6.5; P = .002) or focal extracardiac FDG uptake (adjusted HR 3.8; 95% CI 1.9-7.7; P < .001).
Conclusion
Although CMR and FDG-PET/CT can independently diagnose benign and malignant masses, the combination of these modalities provides complementary value in select cases.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 01 Sep 2021; epub ahead of print
Aghayev A, Cheezum MK, Steigner ML, Mousavi N, ... Di Carli MF, Blankstein R
J Nucl Cardiol: 01 Sep 2021; epub ahead of print | PMID: 34476778
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Impact:
Abstract

Added value of coronary artery calcium score in the reporting of SPECT versus PET myocardial perfusion imaging.

Mouden M, Jager PL, van Dalen JA, van Dijk JD
Background
Knowledge of coronary artery calcium score (CACS) influences the interpretation of myocardial perfusion imaging (MPI) with SPECT; however, the impact on PET interpretation remains unclear. We compared the added value of CACS to reporting MPI using SPECT vs PET.
Methods
We retrospectively included 412 patients. 206 patients who underwent Rb-82 PET were propensity-based matched to a cohort of 4018 patients who underwent cadmium-zinc-telluride SPECT MPI to obtain a comparable group of 206 SPECT patients. Next, we created four image sets: SPECT MPI-only, PET-only, SPECT + CACS, and PET + CACS. Two physicians interpreted the 824 images as normal, equivocal, or abnormal for ischemia or irreversible defects. Additionally, event rates were compared between PET and SPECT groups during 30-month follow-up.
Results
PET yielded more scans interpreted as normal than SPECT (88% vs 80%, respectively, P = 0.015). Adding CACS to SPECT increased the percentage of normal scans to 86% (P = 0.014), whereas this effect was absent for PET (90%, P = 0.77). Annualized event rates for images interpreted as normal did not differ and varied between 0.7 and 2.0% (P > 0.084).
Conclusion
Adding CACS correctly increased the percentage of normal scans for SPECT MPI but not for PET, possibly limiting the effect of adding CACS to reporting PET.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 02 Sep 2021; epub ahead of print
Mouden M, Jager PL, van Dalen JA, van Dijk JD
J Nucl Cardiol: 02 Sep 2021; epub ahead of print | PMID: 34476779
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Impact:
Abstract

Effect of respiratory motion correction and CT-based attenuation correction on dual-gated cardiac PET image quality and quantification.

Schultz J, Siekkinen R, Tadi MJ, Teräs M, ... Saraste A, Teuho J
Background
Dual-gating reduces respiratory and cardiac motion effects but increases noise. With motion correction, motion is minimized and image quality preserved. We applied motion correction to create end-diastolic respiratory motion corrected images from dual-gated images.
Methods
[18F]-fluorodeoxyglucose ([18F]-FDG) PET images of 13 subjects were reconstructed with 4 methods: non-gated, dual-gated, motion corrected, and motion corrected with 4D-CT (MoCo-4D). Image quality was evaluated using standardized uptake values, contrast ratio, signal-to-noise ratio, coefficient of variation, and contrast-to-noise ratio. Motion minimization was evaluated using myocardial wall thickness.
Results
MoCo-4D showed improvement for contrast ratio (2.83 vs 2.76), signal-to-noise ratio (27.5 vs 20.3) and contrast-to-noise ratio (14.5 vs 11.1) compared to dual-gating. The uptake difference between MoCo-4D and non-gated images was non-significant (P > .05) for the myocardium (2.06 vs 2.15 g/mL), but significant (P < .05) for the blood pool (.80 vs .86 g/mL). Non-gated images had the lowest coefficient of variation (27.3%), with significant increase for all other methods (31.6-32.5%). MoCo-4D showed smallest myocardial wall thickness (16.6 mm) with significant decrease compared to non-gated images (20.9 mm).
Conclusions
End-diastolic respiratory motion correction and 4D-CT resulted in improved motion minimization and image quality over standard dual-gating.

© 2021. The Author(s).

J Nucl Cardiol: 02 Sep 2021; epub ahead of print
Schultz J, Siekkinen R, Tadi MJ, Teräs M, ... Saraste A, Teuho J
J Nucl Cardiol: 02 Sep 2021; epub ahead of print | PMID: 34476780
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Impact:
Abstract

Effect of iterations and time of flight on normal distributions of Rb PET relative perfusion and myocardial blood flow.

Poitrasson-Rivière A, Moody JB, Renaud JM, Hagio T, ... Murthy VL, Ficaro EP
Background
As clinical use of myocardial blood flow (MBF) increases, dynamic series are becoming part of the typical workflow. The methods and parameters used to reconstruct these series require investigation to ensure accurate quantification.
Methods
Fifty-nine rest/stress dynamic 82Rb PET studies, acquired on a Biograph mCT, from a combination of normal volunteers and low-likelihood patients were reconstructed with and without time of flight (TOF) for varying iterations and processed to obtain relative perfusion and MBF polar maps. Regional values from mean polar maps were fit to a linear mixed-effect model to quantify convergence and select the optimal number of iterations.
Results
TOF reconstructions converged faster and yielded more uniform relative perfusion polar maps. However, the stress MBF distribution for TOF reconstructions was more heterogeneous, with a higher-intensity septal wall. This phenomenon requires further investigation, with right ventricle blood pool spillover possibly having an effect. Optimal reconstructions were defined as 5-iteration non-TOF (24-subset) reconstructions and 3-iteration TOF (21-subset) reconstructions.
Conclusion
Optimal cardiac reconstructions were identified for non-TOF and TOF reconstructions of dynamic series. TOF reconstruction presents as the more accurate method, given the more uniform relative perfusion distribution.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 25 Aug 2021; epub ahead of print
Poitrasson-Rivière A, Moody JB, Renaud JM, Hagio T, ... Murthy VL, Ficaro EP
J Nucl Cardiol: 25 Aug 2021; epub ahead of print | PMID: 34448094
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Impact:
Abstract

Myocardial flow reserve estimation with contemporary CZT-SPECT and Tc-tracers lacks precision for routine clinical application.

Renaud JM, Poitrasson-Rivière A, Hagio T, Moody JB, ... Ficaro EP, Murthy VL
Background
PET myocardial flow reserve (MFR) has established diagnostic and prognostic value. Technological advances have now enabled SPECT MFR quantification. We investigated whether SPECT MFR precision is sufficient for clinical categorization of patients.
Methods
Validation studies vs invasive flow measurements and PET MFR were reviewed to determine global SPECT MFR thresholds. Studies vs PET and a SPECT MFR repeatability study were used to establish imprecision in SPECT MFR measurements as the standard deviation of the difference between SPECT and PET MFR, or test-retest SPECT MFR. Simulations were used to evaluate the impact of SPECT MFR imprecision on confidence of clinically relevant categorization.
Results
Based on validation studies, the typical PET MFR categories were used for SPECT MFR classification (< 1.5, 1.5-2.0, > 2.0). Imprecision vs PET MFR ranged from 0.556 to 0.829, and test-retest imprecision was 0.781-0.878. Simulations showed correct classification of up to only 34% of patients when 1.5 ≤ true MFR ≤ 2.0. Categorization with high confidence (> 80%) was only achieved for extreme MFR values (< 1.0 or > 2.5), with correct classification in only 15% of patients in a typical lab with MFR of 1.8 ± 0.5.
Conclusions
Current SPECT-derived estimates of MFR lack precision and require further optimization for clinical risk stratification.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 22 Aug 2021; epub ahead of print
Renaud JM, Poitrasson-Rivière A, Hagio T, Moody JB, ... Ficaro EP, Murthy VL
J Nucl Cardiol: 22 Aug 2021; epub ahead of print | PMID: 34426935
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Impact:
Abstract

Serial changes of myocardial perfusion imaging in takotsubo and reverse takotsubo cardiomyopathy.

Miyajima K, Tawarahara K, Saito N
Background
Takotsubo cardiomyopathy (TTC) shows reversible hypokinesis in the left ventricular (LV) apical-half segment and hyperkinesis in the LV basal-half segment. However, the precise pathophysiological mechanism of TTC is unclear. Therefore, this study sought to clarify the nuclear characteristics, degree of myocardial damage, and serial change of TTC and rTTC using myocardial perfusion imaging.
Methods
We performed myocardial perfusion scintigraphy in 28 patients (TTC: 20, rTTC: 8) using Tc-99m sestamibi and assessed minimum percentage uptake (min-%-uptake), extent score (ES) and summed rest score (SRS) at acute and chronic phases.
Results
Min-%-uptake improved from the acute to the chronic phase (TTC: 54 [48-59]% vs 87 [81-90]%, P  < 0.01; rTTC: 60 [55-64]% vs 77 [71-79]%, P < 0.01), as did the ES (TTC: 32 [26-41]% vs 0.0 [0.0-6.0]%, P < 0.01; rTTC: 16 [12-34]% vs 0.0 [0.0-0.0]%, P = 0.02) and SRS (TTC: 4.5 [3.9-5.3] vs 0.0 [0.0-0.2], P < 0.01; rTTC: 3.6 [3.3-3.8] vs 0.0 [0.0-0.0], P = 0.01).
Conclusion
Tc-99m sestamibi uptake was reduced in hypokinetic regions in the acute phase and improved in the chronic phase. TTC and rTTC may involve a reversible disorder of the myocardial cell membrane, mitochondria, and microcirculation.

© 2021. The Author(s).

J Nucl Cardiol: 23 Aug 2021; epub ahead of print
Miyajima K, Tawarahara K, Saito N
J Nucl Cardiol: 23 Aug 2021; epub ahead of print | PMID: 34427859
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Impact:
Abstract

The prognostic value of positron emission tomography in the evaluation of suspected cardiac sarcoidosis.

Patel VN, Pieper JA, Poitrasson-Rivière A, Kopin D, ... Murthy VL, Koelling T
Objectives
To assess the prognostic value of positron emission tomography (PET) imaging in patients undergoing evaluation for known or suspected cardiac sarcoidosis (CS) while not on active immunotherapy.
Background
Previous studies have attempted to identify the value of PET imaging to aid in risk stratification of patients with CS, however, most cohorts have included patients currently on immunosuppression, which may confound scan results by suppressing positive findings.
Methods
We retrospectively analyzed 197 patients not on immunosuppression who underwent 18F-fluorodeoxyglucose (FDG) PET scans for evaluation of known or suspected CS. The primary endpoint of the study was time to ventricular arrhythmia (VT/VF), or death. Candidate predictors were identified by univariable Cox proportional hazards regression. Independent predictors were identified by performing multivariable Cox regression with stepwise forward selection.
Results
Median follow-up time was 531 [IQR 309, 748] days. 41 patients met the primary endpoint. After stepwise forward selection, left ventricular ejection fraction (LVEF) (HR 0.98, 95% CI 0.96-0.99, P = 0.02), history of VT/VF (HR 4.19, 95% CI 2.15-8.17, P < 0.001), and summed rest score (SRS) (HR 1.06, 95% CI 1.02-1.12, P = 0.01) were predictive of the primary endpoint. Quantitative and qualitative measures of FDG uptake on PET were not predictive of clinical events.
Conclusions
Among untreated patients who underwent PET scans to evaluate known or suspected CS, LVEF, history of VT/VF, and SRS were associated with adverse clinical outcomes.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 08 Sep 2021; epub ahead of print
Patel VN, Pieper JA, Poitrasson-Rivière A, Kopin D, ... Murthy VL, Koelling T
J Nucl Cardiol: 08 Sep 2021; epub ahead of print | PMID: 34505261
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Abstract

Association Between Impaired Myocardial Flow Reserve on Rubidium Positron Emission Tomography Imaging and Adverse Events in Patients With Autoimmune Rheumatic Disease.

Feher A, Boutagy NE, Oikonomou EK, Liu YH, ... Sinusas AJ, Hinchcliff M
Background
Coronary microvascular dysfunction has been described in patients with autoimmune rheumatic disease (ARD). However, it is unknown whether positron emission tomography (PET)-derived myocardial flow reserve (MFR) can predict adverse events in this population.
Methods
Patients with ARD without coronary artery disease who underwent dynamic rest-stress 82Rubidium PET were retrospectively studied and compared with patients without ARD matched for age, sex, and comorbidities. The association between MFR and a composite end point of mortality or myocardial infarction or heart failure admission was evaluated with time to event and Cox-regression analyses.
Results
In 101 patients with ARD (88% female, age: 62±10 years), when compared with matched patients without ARD (n=101), global MFR was significantly reduced (median: 1.68 [interquartile range: 1.34-2.05] versus 1.86 [interquartile range: 1.58-2.28]) and reduced MFR (<1.5) was more frequent (40% versus 22%). MFR did not differ among subtypes of ARDs. In survival analysis, patients with ARD and low MFR (MFR<1.5) had decreased event-free survival for the combined end point, when compared with patients with and without ARD and normal MFR (MFR>1.5) and when compared with patients without ARD and low MFR, after adjustment for the nonlaboratory-based Framingham risk score, rest left ventricular ejection fraction, severe coronary calcification, and the presence of medium/large perfusion defects. In Cox-regression analysis, ARD diagnosis and reduced MFR were both independent predictors of adverse events along with congestive heart failure diagnosis and presence of medium/large stress perfusion defects on PET. Further analysis with inclusion of an interaction term between ARD and impaired MFR revealed no significant interaction effects between ARD and impaired MFR.
Conclusions
In our retrospective cohort analysis, patients with ARD had significantly reduced PET MFR compared with age-, sex-, and comorbidity-matched patients without ARD. Reduced PET MFR and ARD diagnosis were both independent predictors of adverse outcomes.



Circ Cardiovasc Imaging: 09 Sep 2021:CIRCIMAGING120012208; epub ahead of print
Feher A, Boutagy NE, Oikonomou EK, Liu YH, ... Sinusas AJ, Hinchcliff M
Circ Cardiovasc Imaging: 09 Sep 2021:CIRCIMAGING120012208; epub ahead of print | PMID: 34503339
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Abstract

Effect of changes in perfusion defect size during serial stress myocardial perfusion imaging on cardiovascular outcomes in patients treated with primary percutaneous coronary intervention after myocardial infarction.

Zampella E, Mannarino T, Gaudieri V, D\'Antonio A, ... Cuocolo A, Acampa W
Background
We evaluated the prognostic value of changes in perfusion defect size (PDS) on serial MPS in patients treated with primary percutaneous coronary intervention (PCI) after acute myocardial infarction (AMI).
Methods
We enrolled 112 patients treated with primary PCI after AMI who underwent two stress MPS within 1 month and after 6 months. Improvement in PDS was defined as a reduction ≥5%. Remodeling was defined as an increase in left ventricular (LV) end-diastolic volume index ≥20%. Cardiac events included cardiac death, nonfatal MI, unstable angina, repeated revascularization, and heart failure.
Results
During a median follow-up of 86 months, 22 events occurred. Event rate was higher (P < .01) in patients with worsening of PDS compared to those with unchanged or improved PDS. Moreover, patients with remodeling had a higher (P < .001) event rate compared to those without. At Cox analysis, worsening of PDS and remodeling resulted independent predictors of events (both P < .01). Patients with both worsening of PDS and remodeling had the worst event-free survival (P <.001).
Conclusion
In patients treated with primary PCI after AMI, worsening of PDS and remodeling are associated to higher risk of events at long-term follow-up. Gated stress MPS improves risk stratification in these patients.

© 2021. American Society of Nuclear Cardiology.

J Nucl Cardiol: 12 Sep 2021; epub ahead of print
Zampella E, Mannarino T, Gaudieri V, D'Antonio A, ... Cuocolo A, Acampa W
J Nucl Cardiol: 12 Sep 2021; epub ahead of print | PMID: 34519009
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Impact:
Abstract

Prognostic Implications of Left Ventricular Myocardial Work Indices in Patients With Secondary Mitral Regurgitation.

Yedidya I, Lustosa RP, Fortuni F, van der Bijl P, ... Bax JJ, Delgado V
Background
Assessment of left ventricular (LV) function in patients with secondary mitral regurgitation (SMR) remains challenging but is an important parameter for risk stratification. The association of LV myocardial work components (work index [GWI], constructive [GCW] and wasted [GWW] work, and work efficiency) derived from pressure-strain loops obtained with speckle tracking echocardiography, and all-cause mortality in patients with SMR was investigated.
Methods
LV myocardial GWI, GCW, GWW, and global work efficiency were measured with speckle tracking strain echocardiography in 373 patients (72% men, median age 68 years) with various grades of SMR. All-cause mortality was the primary end point.
Results
Mild SMR was observed in 143 patients, 128 had moderate SMR, and 102 had severe SMR. Patients with severe SMR had the largest LV volumes and the worst LV ejection fraction and LV global longitudinal strain. In patients with severe SMR, LV GWI and GCW were more impaired (500 mm Hg% versus 680 mm Hg% P=0.024 and 678 mm Hg% versus 851 mm Hg% P=0.006, respectively), while GWW was lower (130 mm Hg% versus 260 mm Hg% P<0.001, respectively) and global work efficiency was significantly higher (82% versus 76%, P=0.001) compared with patients with mild SMR. After a median follow-up of 56 months, 161 patients died. LV GWI≤500 mm Hg%, LV GCW≤750 mm Hg%, and LV GWW<300 mm Hg% were independently associated with excess mortality.
Conclusions
Patients with severe SMR had the worst LV GWI and LV GCW but better LV GWW and global work efficiency reflecting the unloading of the LV in the low-pressure left atrial chamber. These parameters were independently associated with worse long-term survival in patients with SMR.



Circ Cardiovasc Imaging: 14 Sep 2021:CIRCIMAGING120012142; epub ahead of print
Yedidya I, Lustosa RP, Fortuni F, van der Bijl P, ... Bax JJ, Delgado V
Circ Cardiovasc Imaging: 14 Sep 2021:CIRCIMAGING120012142; epub ahead of print | PMID: 34521214
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Impact:
Abstract

[F]FDG and [F]NaF as PET markers of systemic atherosclerosis progression: A longitudinal descriptive imaging study in patients with type 2 diabetes mellitus.

Reijrink M, de Boer SA, Te Velde-Keyzer CA, Sluiter JKE, ... Mulder DJ, Slart RHJA
Background
While [18F]-fluordeoxyglucose ([18F]FDG) uptake is associated with arterial inflammation, [18F]-sodium fluoride ([18F]NaF) is a marker for arterial micro-calcification. We aimed to investigate the prospective correlation between both PET markers over time and whether they are prospectively ([18F]FDG) and retrospectively ([18F]NaF) related to progression of systemic arterial disease in a longitudinal study in patients with type 2 diabetes mellitus (T2DM).
Methods
Baseline [18F]FDG PET/Low Dose (LD) Computed Tomography (CT) scans of ten patients with early T2DM without cardiovascular history (70% men, median age 63 years) were compared with five-year follow-up [18F]NaF/LDCT scans. Systemic activity was expressed as mean target-to-background ratio (meanTBR) by dividing the maximal standardized uptake value (SUVmax) of ten arteries by SUVmean of the caval vein. CT-assessed macro-calcifications were scored visually and expressed as calcified plaque (CP) score. Arterial stiffness was assessed with carotid-femoral pulse wave velocity (PWV). Five-year changes were expressed absolutely with delta (Δ) and relatively with %change.
Results
Baseline meanTBR[18F]FDG was strongly correlated with five-year follow-up meanTBR[18F]NaF (r = 0.709, P = .022). meanTBR[18F]NaF correlated positively with ΔCPscore, CPscore at baseline, and follow-up (r = 0.845, P = .002 and r = 0.855, P = .002, respectively), but not with %change in CPscore and PWV.
Conclusion
This proof-of-concept study demonstrated that systemic arterial inflammation is an important pathogenetic factor in systemic arterial micro-calcification development.

© 2021. The Author(s).

J Nucl Cardiol: 12 Sep 2021; epub ahead of print
Reijrink M, de Boer SA, Te Velde-Keyzer CA, Sluiter JKE, ... Mulder DJ, Slart RHJA
J Nucl Cardiol: 12 Sep 2021; epub ahead of print | PMID: 34519008
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Abstract

Prognostic Value of Complementary Echocardiography and Magnetic Resonance Imaging Quantitative Evaluation for Isolated Tricuspid Regurgitation.

Wang TKM, Akyuz K, Reyaldeen R, Griffin BP, ... Xu B, Desai MY
Background
Isolated tricuspid regurgitation (TR) remains a management dilemma with poor outcomes. Echocardiography and cardiac magnetic resonance imaging (CMR) are valuable tools for evaluating TR, but their prognostic utility has rarely been studied together in this setting. We aimed to determine the prognostic value and thresholds for echocardiography and CMR parameters for isolated severe TR.
Methods
Consecutive patients with isolated severe TR by echocardiography and undergoing CMR during January 2007 to June 2019 were studied. Echocardiography and CMR-derived quantitative parameters were analyzed for independent associations with and thresholds for predicting the primary end point of all-cause mortality during follow-up.
Results
Among 262 patients studied, mean age was 62.8±15.6 years, 156 (59.5%) were females, 207 (79.0%) had secondary TR, and 87 (33.2%) underwent tricuspid valve surgery after CMR. There were 68 (26.0%) deaths during a mean follow-up of 2.5 years. Both CMR-derived tricuspid regurgitant fraction (per 5% increase) and right ventricle free wall longitudinal strain (per 1% decrease in magnitude) were independently associated with worse survival, with hazard ratios (95% CIs) of 1.15 (1.05-1.25) and 1.10 (1.04-1.17), respectively, along with right heart failure symptoms of 2.03 (1.14-3.60), while tricuspid valve surgery was borderline protective with 0.55 (0.31-0.997). Regurgitant fraction ≥30%, regurgitant volume ≥35 mL and right ventricle free wall longitudinal strain ≥-11% (by velocity vector imaging technique, which yields lower magnitude values than other conventional strain techniques) were the optimal thresholds for mortality during follow-up.
Conclusions
TR quantification by CMR and right ventricle free wall longitudinal strain by echocardiography were the key imaging parameters independently associated with reduced survival in isolated TR, incremental to conventional clinical factors. Clinically significant thresholds for these parameters were determined and may help guide decision-making for TR management.



Circ Cardiovasc Imaging: 14 Sep 2021:CIRCIMAGING120012211; epub ahead of print
Wang TKM, Akyuz K, Reyaldeen R, Griffin BP, ... Xu B, Desai MY
Circ Cardiovasc Imaging: 14 Sep 2021:CIRCIMAGING120012211; epub ahead of print | PMID: 34521215
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Abstract

A simplified wall-based model for regional innervation/perfusion mismatch assessed by cardiac 123I-mIBG and rest 99mTc-tetrofosmin SPECT to predict arrhythmic events in ischaemic heart failure.

Verschure DO, Poel E, Travin MI, Henzlova MJ, ... Jacobson AF, Verberne HJ
Aims
Cardiac 123iodine-meta-iodobenzylguanidine (123I-mIBG) single-photon emission computed tomography (SPECT) imaging provides information on regional myocardial innervation. However, the value of the commonly used 17-segment summed defect score (SDS) as a prognostic marker is uncertain. The present study examined whether a simpler regional scoring approach for evaluation of 123I-mIBG SPECT combined with rest 99mTc-tetrofosmin SPECT myocardial perfusion imaging could improve prediction of arrhythmic events (AEs) in patients with ischaemic heart failure (HF).
Methods and results
Five hundred and two ischaemic HF subjects of the ADMIRE-HF study with complete cardiac 123I-mIBG and rest 99mTc-tetrofosmin SPECT studies were included. Both SPECT image sets were read together by two experienced nuclear imagers and scored by consensus. In addition to standard 17-segment scoring, the readers classified walls (i.e. anterior, lateral, inferior, septum and apex) as normal, matched defect, mismatched (innervation defect > perfusion defect), or reverse mismatched (perfusion defect > innervation defect). Cox proportional hazards ratios (HRs) were used to determine if age, body mass index, functional class, left ventricular ejection fraction (LVEF), B-type natriuretic peptide (BNP), norepinephrine, 123I-mIBG SDS, 99mTc-tetrofosmin SDS, innervation/perfusion mismatch SDS, and our simplified visual innervation/perfusion wall classification were associated with occurrence of AEs (i.e. sudden cardiac death, sustained ventricular tachycardia, resuscitated cardiac arrest, appropriate implantable cardioverter-defibrillator therapy). At 2-year median follow-up, 52 subjects (10.4%) had AEs. Subjects with 1 or 2 mismatched walls were twice as likely to have AEs compared with subjects with either 0 or 3-5 mismatched walls (16.3% vs. 8.3%, P = 0.010). Cox regression analyses showed that patients with a visual mismatch in 1-2 walls had an almost two times higher risk of AEs [HR 2.084 (1.109-3.914), P = 0.001]. None of the other innervation, perfusion and mismatch scores using standard 17 segments were associated with AEs. BNP (ng/L) was the only non-imaging parameter associated with AEs.
Conclusion
A visual left ventricular wall-level based scoring method identified highest AE risk in ischaemic HF subjects with intermediate levels of innervation/perfusion mismatches. This simple technique for the evaluation of SPECT studies, which are often challenging in HF subjects, seems to be superior to the 17-segment scoring method.

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

Eur Heart J Cardiovasc Imaging: 23 Aug 2021; epub ahead of print
Verschure DO, Poel E, Travin MI, Henzlova MJ, ... Jacobson AF, Verberne HJ
Eur Heart J Cardiovasc Imaging: 23 Aug 2021; epub ahead of print | PMID: 34427293
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Abstract

Impact of Echocardiographic Guidance on Safety and Efficacy of Left Atrial Appendage Closure: An Observational Study.

Galea R, Räber L, Fuerholz M, Häner JD, ... Windecker S, Valgimigli M
Objectives
The aim of this study was to evaluate the impact of echocardiographic guidance on the safety and efficacy of left atrial appendage closure (LAAC).
Background
Expert consensus documents recommend intraprocedural imaging by means of either transesophageal echocardiography or intracardiac echocardiography to guide LAAC. However, no evidence exists that intraprocedural echocardiographic guidance in addition to fluoroscopy improves the safety and efficacy of LAAC.
Methods
Consecutive LAAC procedures performed at a high-volume center between January 2009 and October 2020 were stratified on the basis of intraprocedural imaging modalities, including fluoroscopic guidance (FG) only or intraprocedural echocardiographic guidance (EG) in addition to fluoroscopy. The primary safety endpoint was the composite of procedure-related complications occurring within 7 days after the procedure. Technical success at 7 days and at follow-up were secondary endpoints.
Results
Among 811 LAAC procedures, 549 (67.7%) and 262 (32.3%) were assigned to the FG and EG groups, respectively. After adjusting for confounders, EG remained associated with a lower rate of the primary safety endpoint (3.4% vs 9.1%; P = 0.004; adjusted odds ratio [OR]: 0.31; 95% CI: 0.11-0.90; P = 0.030). Technical success trended higher at 7 days (92.1% vs 87.2%; P = 0.065; adjusted OR: 1.68; 95% CI: 0.95-3.01; P = 0.079) and was significantly improved with EG compared with FG (87.6% vs 79.9%; P = 0.018; OR: 4.06; 95% CI: 1.60-10.27; P = 0.003) after a median follow-up period of 4.9 months (interquartile range: 3.4 months-6.2 months).
Conclusions
In a large cohort of consecutive LAACs, the use of intraprocedural echocardiography to guide intervention in addition to standard fluoroscopy was associated with lower risks for procedural complications and higher mid-term technical success rates.

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

JACC Cardiovasc Interv: 22 Aug 2021; 14:1815-1826
Galea R, Räber L, Fuerholz M, Häner JD, ... Windecker S, Valgimigli M
JACC Cardiovasc Interv: 22 Aug 2021; 14:1815-1826 | PMID: 34412799
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Abstract

The Association of Chronic Kidney Disease With Outcomes Following Percutaneous Left Atrial Appendage Closure.

Ahuja KR, Ariss RW, Nazir S, Vyas R, ... Macciocca M, Moukarbel GV
Objectives
The aim of this study was to investigate the associations of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with in-hospital and short-term outcomes using a large national database representative of contemporary clinical practice.
Background
CKD and ESRD are associated with increased risk for stroke and bleeding in patients with atrial fibrillation on oral anticoagulation. Left atrial appendage closure (LAAC) may provide a reasonable alternative for these patients; however, the impact of CKD and ESRD on in-hospital and short-term outcomes following LAAC remain largely unknown.
Methods
The Nationwide Readmissions Database was used to identify LAAC procedures from 2016 to 2017 in patients with no CKD, CKD (stages I-V), and ESRD. Multivariable logistic regression models were used to assess in-hospital and short-term outcomes. The primary outcome was in-hospital mortality.
Results
Of 21,274 patients who underwent LAAC during the study period, 3,954 (18.6%) had CKD and 571 (2.7%) had ESRD. ESRD was associated with increased risk for in-hospital mortality compared with no CKD (3.3% vs 0.4%; adjusted odds ratio: 6.48; 95% confidence interval: 3.35-12.50; P < 0.001) and CKD (3.3% vs 0.5%; adjusted odds ratio: 11.43; 95% confidence interval: 4.77-27.39; P < 0.001). CKD was associated with increased risk for in-hospital acute kidney injury or hemodialysis and stroke or transient ischemic attack. ESRD and CKD were associated with increased readmissions extending to 90 days compared with no CKD, and ESRD was associated with increased readmissions compared with CKD. There was no difference with respect to other in-hospital outcomes.
Conclusions
ESRD is associated with higher in-hospital mortality, and CKD is associated with higher rates of stroke or transient ischemic attack in patients undergoing LAAC. Further research is needed to assess the impact of CKD and ESRD on long-term outcomes in these patients.

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

JACC Cardiovasc Interv: 22 Aug 2021; 14:1830-1839
Ahuja KR, Ariss RW, Nazir S, Vyas R, ... Macciocca M, Moukarbel GV
JACC Cardiovasc Interv: 22 Aug 2021; 14:1830-1839 | PMID: 34412801
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Abstract

Changes in left atrial structure and function over a decade in the general population.

Olsen FJ, Johansen ND, Skaarup KG, Lassen MCH, ... Møgelvang R, Biering-Sørensen T
Aims
Assessing left atrial (LA) size and function is an important part of the echocardiographic examination. We sought to assess how LA size and function develop over time, and which clinical characteristics promote atrial remodelling.
Methods and results
We examined longitudinal changes of the LA between two visits in the Copenhagen City Heart Study (n = 1065). The median time between the examinations was 10.4 years. LA measurements included: maximal LA volume (LAVmax), minimal LA volume (LAVmin), and LA emptying fraction (LAEF). Clinical and echocardiographic accelerators were determined from linear regression. The value of LA remodelling for predicting incident atrial fibrillation (AF) and heart failure (HF) was examined by Cox proportional hazards regressions. During follow-up, LAVmax and LAVmin significantly increased by 8.3 and 3.5 mL/m2, respectively. LAEF did not change. Age and AF were the most impactful clinical accelerators of LA remodelling with standardized beta-coefficients of 0.17 and 0.28 for changes in LAVmax, and 0.18 and 0.38 for changes in LAVmin, respectively. Left ventricular (LV) systolic function, diameter, and mass were also significant accelerators of LA remodelling. Changes in both LAVmax and LAVmin were significantly associated with incident AF [n = 46, ΔLAVmax: HR = 1.06 (1.03-1.09), P < 0.001 and ΔLAVmin: HR = 1.14 (1.10-1.18), P < 0.001, per 1 mL/m2 increase] and HF [n = 27, ΔLAVmax: HR = 1.08 (1.04-1.12), P < 0.001 and ΔLAVmin: HR = 1.13 (1.09-1.18), P < 0.001, per 1 mL/m2 increase].
Conclusion
Both maximal and minimal LA volume increase over time. Clinical accelerators included age and AF. LV structure and systolic function also accelerate LA remodelling. LA remodelling poses an increased risk of clinical outcomes.

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

Eur Heart J Cardiovasc Imaging: 31 Aug 2021; epub ahead of print
Olsen FJ, Johansen ND, Skaarup KG, Lassen MCH, ... Møgelvang R, Biering-Sørensen T
Eur Heart J Cardiovasc Imaging: 31 Aug 2021; epub ahead of print | PMID: 34468711
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Abstract

Measurement of compensatory arterial remodelling over time with serial coronary computed tomography angiography and 3D metrics.

van den Hoogen IJ, van Rosendael AR, Lin FY, Gianni U, ... Shaw LJ, Bax JJ
Aims
The magnitude of alterations in which coronary arteries remodel and narrow over time is not well understood. We aimed to examine changes in coronary arterial remodelling and luminal narrowing by three-dimensional (3D) metrics from serial coronary computed tomography angiography (CCTA).
Methods and results
From a multicentre registry of patients with suspected coronary artery disease who underwent clinically indicated serial CCTA (median interscan interval = 3.3 years), we quantitatively measured coronary plaque, vessel, and lumen volumes on both scans. Primary outcome was the per-segment change in coronary vessel and lumen volume from a change in plaque volume, focusing on arterial remodelling. Multivariate generalized estimating equations including statins were calculated comparing associations between groups of baseline percent atheroma volume (PAV) and location within the coronary artery tree. From 1245 patients (mean age 61 ± 9 years, 39% women), a total of 5721 segments were analysed. For each 1.00 mm3 increase in plaque volume, the vessel volume increased by 0.71 mm3 [95% confidence interval (CI) 0.63 to 0.79 mm3, P < 0.001] with a corresponding reduction in lumen volume by 0.29 mm3 (95% CI -0.37 to -0.21 mm3, P < 0.001). Serial 3D arterial remodelling and luminal narrowing was similar in segments with low and high baseline PAV (P ≥ 0.496). No differences were observed between left main and non-left main segments, proximal and distal segments and side branch and non-side branch segments (P ≥ 0.281).
Conclusions
Over time, atherosclerotic coronary plaque reveals prominent outward arterial remodelling that co-occurs with modest luminal narrowing. These findings provide additional insight into the compensatory mechanisms involved in the progression of coronary atherosclerosis.

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

Eur Heart J Cardiovasc Imaging: 31 Aug 2021; epub ahead of print
van den Hoogen IJ, van Rosendael AR, Lin FY, Gianni U, ... Shaw LJ, Bax JJ
Eur Heart J Cardiovasc Imaging: 31 Aug 2021; epub ahead of print | PMID: 34468717
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Impact:
Abstract

Sex differences in left ventricular remodelling in patients with severe aortic valve stenosis.

Kuneman JH, Singh GK, Milhorini Pio S, Hirasawa K, ... Delgado V, Bax JJ
Aims 
Women with severe aortic stenosis (AS) have better long-term outcome after transcatheter aortic valve implantation (TAVI) but worse survival after surgical aortic valve replacement compared with men. Whether this is related to sex differences in left ventricular (LV) remodelling is unknown. The aim of this study was to examine the sex differences in LV remodelling with multidetector row computed tomography (MDCT) and outcome in patients with severe AS undergoing TAVI between 2007 and 2018.
Methods and results 
A total of 289 patients (age 80 ± 6 years, 54% male) were included. LV volumes, mass, and function were analysed on pre-procedural MDCT scans. Women showed smaller LV volumes and mass compared with men. Patients were classified into four LV remodelling patterns: concentric hypertrophy (50%) was the most frequent pattern of LV remodelling followed by eccentric hypertrophy (33%), normal geometry (13%), and concentric remodelling (4%). Men showed more concentric remodelling compared with women (91% vs. 9%, respectively, P = 0.011). However, no differences were observed in the remaining LV remodelling patterns. During a median follow-up of 3.8 (IQR 2.2-5.1) years after TAVI, 87 (30%) patients died. Women demonstrated better outcome after TAVI compared with men (log-rank χ2 = 4.29, P = 0.038). No association was observed between the interaction of the LV remodelling patterns and sex with outcome.
Conclusion 
LV concentric hypertrophy and eccentric hypertrophy are similarly observed in men and women with severe AS but concentric remodelling was more common in men. Women demonstrated better outcome after TAVI when compared with men. The interaction between the LV remodelling patterns and sex was not associated with survival.

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

Eur Heart J Cardiovasc Imaging: 31 Aug 2021; epub ahead of print
Kuneman JH, Singh GK, Milhorini Pio S, Hirasawa K, ... Delgado V, Bax JJ
Eur Heart J Cardiovasc Imaging: 31 Aug 2021; epub ahead of print | PMID: 34468719
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Impact:
Abstract

Clinical impact of left atrial appendage filling defects in patients undergoing transcatheter aortic valve implantation.

Okuno T, Lanz J, Stortecky S, Heg D, ... Windecker S, Pilgrim T
Aims
Incidental detection of left atrial appendage (LAA) filling defects is a common finding on multi-detector computed tomography in aortic stenosis patients under evaluation for transcatheter aortic valve implantation (TAVI). We aimed to investigate the incidence of LAA filling defects before TAVI and its impact on clinical outcomes.
Methods and results
In a prospective registry, LAA filling defects were retrospectively evaluated and categorized into one of four sub-types: thrombus-like, heterogeneous, horizontal, and Hounsfield Unit (HU)-run-off. The primary endpoint was the composite of cardiovascular death or disabling stroke up to 1-year follow-up. Among 1621 patients undergoing TAVI between August 2007 and June 2018, LAA filling defects were present in 177 patients (11%), and categorized as thrombus-like in 22 (1.4%), heterogeneous in 37 (2.3%), horizontal in 80 (4.9%), and HU-run-off in 38 (2.4%). Compared to patients with normal LAA filling, patients with LAA filling defects had greater prevalence of atrial fibrillation (84.7% vs. 26.4%, P < 0.001) and history of cerebrovascular events (16.4% vs. 10.9%, P = 0.045). The primary endpoint occurred in 131 patients (9.2%) with normal LAA filling and in 36 patients (21.2%) with LAA filling defects (P < 0.001). Subgroup analysis suggested that the risk of disabling stroke was greatest in the thrombus-like pattern (23.0%), followed by the HU-run-off (8.0%), the heterogeneous (6.2%), and the horizontal pattern (1.2%).
Conclusion
LAA filling defects were observed in 11% of aortic stenosis patients undergoing TAVI and associated with an increased risk of cardiovascular death and disabling stroke up to 1 year following TAVI.
Trial registration
https://www.clinicaltrials.gov. NCT01368250.

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

Eur Heart J Cardiovasc Imaging: 30 Aug 2021; epub ahead of print
Okuno T, Lanz J, Stortecky S, Heg D, ... Windecker S, Pilgrim T
Eur Heart J Cardiovasc Imaging: 30 Aug 2021; epub ahead of print | PMID: 34463717
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Impact:
Abstract

The year 2020 in the European Heart Journal - Cardiovascular Imaging: part I.

Edvardsen T, Donal E, Marsan NA, Maurovich-Horvat P, ... Petersen SE, Cosyns B
The European Heart Journal - Cardiovascular Imaging was launched in 2012 and has during these 9 years become one of the leading multimodality cardiovascular imaging journals. The journal is currently ranked as number 20 among all cardiovascular journals. Our journal is well established as one of the top cardiovascular journals and is the most important cardiovascular imaging journal in Europe. The most important studies published in our Journal in 2020 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.

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

Eur Heart J Cardiovasc Imaging: 30 Aug 2021; epub ahead of print
Edvardsen T, Donal E, Marsan NA, Maurovich-Horvat P, ... Petersen SE, Cosyns B
Eur Heart J Cardiovasc Imaging: 30 Aug 2021; epub ahead of print | PMID: 34463734
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Abstract

Impact of HAS-BLED Score on outcome after percutaneous left atrial appendage closure: insights from the German Left Atrial Appendage Occluder Registry LAARGE.

Ledwoch J, Franke J, Brachmann J, Lewalter T, ... Krapivsky A, Sievert H
Aim
Percutaneous left atrial appendage (LAA) closure has been established as alternative stroke prophylaxis in patients with non-valvular atrial fibrillation (AF) and high bleeding risk. However, little is known regarding the outcome after LAA closure depending on the HAS-BLED score.
Methods
A sub-analysis of the prospective, multicenter, Left-Atrium-Appendage Occluder Register-GErmany (LAARGE) registry was performed assessing three different groups with respect to the HAS-BLED score (0-2 [group 1] vs. 3-4 [group 2] vs. 5-7 [group 3]).
Results
A total of 633 patients at 38 centers were enrolled. Of them, 9% (n = 59) were in group 1, 63% (n = 400) in group 2 and 28% (n = 174) in group 3. The Kaplan-Meier estimated 1-year composite of death, stroke and systemic embolism was 3.4% in group 1 vs. 10.4% in group 2 vs. 20.1% in group 3, respectively (p log-rank < 0.001). The difference was driven by death since stroke and systemic embolism did not show a significant difference between the groups. The rate of major bleeding at 1 year was 0% vs. 0% vs. 2.4%, respectively (p = 0.016).
Conclusion
The present data show that patients had similarly low rates of ischemic complications 1 year after LAA closure irrespective of the baseline bleeding risk. Higher HAS-BLED scores were associated with increased mortality due to higher age and more severe comorbidity of these patients.

© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.

Clin Res Cardiol: 27 Aug 2021; epub ahead of print
Ledwoch J, Franke J, Brachmann J, Lewalter T, ... Krapivsky A, Sievert H
Clin Res Cardiol: 27 Aug 2021; epub ahead of print | PMID: 34455462
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Abstract

Risk prediction in patients with COVID-19 based on haemodynamic assessment of left and right ventricular function.

Taieb P, Szekely Y, Lupu L, Ghantous E, ... Banai S, Topilsky Y
Aims
Cardiovascular involvement is common in COVID-19. We sought to describe the haemodynamic profiles of hospitalized COVID-19 patients and determine their association with mortality.
Methods and results
Consecutive hospitalized patients diagnosed with COVID-19 infection underwent clinical evaluation using the Modified Early Warning Score (MEWS) and a full non-invasive echocardiographic haemodynamic evaluation, irrespective of clinical indication, as part of a prospective predefined protocol. Patients were stratified based on filling pressure and output into four groups. Multivariable Cox-Hazard analyses determined the association between haemodynamic parameters with mortality. Among 531 consecutive patients, 44% of patients had normal left ventricular (LV) and right ventricular (RV) haemodynamic status. In contrast to LV haemodynamic parameters, RV parameters worsened with higher MEWS stage. While RV parameters did not have incremental risk prediction value above MEWS, LV stroke volume index, E/e\' ratio, and LV stroke work index were all independent predictors of outcome, particularly in severe disease. Patients with LV or RV with high filling pressure and low output had the worse outcome, and patients with normal haemodynamics had the best (P < 0.0001).
Conclusion
In hospitalized patients with COVID-19, almost half have normal left and right haemodynamics at presentation. RV but not LV haemodynamics are related to easily obtainable clinical parameters. LV but not RV haemodynamics are independent predictors of mortality, mostly in patients with severe disease.

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

Eur Heart J Cardiovasc Imaging: 27 Aug 2021; epub ahead of print
Taieb P, Szekely Y, Lupu L, Ghantous E, ... Banai S, Topilsky Y
Eur Heart J Cardiovasc Imaging: 27 Aug 2021; epub ahead of print | PMID: 34453517
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Abstract

Adverse right ventricular remodelling, function, and stress responses in obesity: insights from cardiovascular magnetic resonance.

Lewis AJM, Abdesselam I, Rayner JJ, Byrne J, ... Neubauer S, Rider OJ
Aims
We aimed to determine the effect of increasing body weight upon right ventricular (RV) volumes, energetics, systolic function, and stress responses using cardiovascular magnetic resonance (CMR).
Methods and results
We first determined the effects of World Health Organization class III obesity [body mass index (BMI) > 40 kg/m2, n = 54] vs. healthy weight (BMI < 25 kg/m2, n = 49) upon RV volumes, energetics and systolic function using CMR. In less severe obesity (BMI 35 ± 5 kg/m2, n = 18) and healthy weight controls (BMI 21 ± 1 kg/m2, n = 9), we next performed CMR before and during dobutamine to evaluate RV stress response. A subgroup undergoing bariatric surgery (n = 37) were rescanned at median 1 year to determine the effects of weight loss. When compared with healthy weight, class III obesity was associated with adverse RV remodelling (17% RV end-diastolic volume increase, P < 0.0001), impaired cardiac energetics (19% phosphocreatine to adenosine triphosphate ratio reduction, P < 0.001), and reduction in RV ejection fraction (by 3%, P = 0.01), which was related to impaired energetics (R = 0.3, P = 0.04). Participants with less severe obesity had impaired RV diastolic filling at rest and blunted RV systolic and diastolic responses to dobutamine compared with healthy weight. Surgical weight loss (34 ± 15 kg weight loss) was associated with improvement in RV end-diastolic volume (by 8%, P = 0.006) and systolic function (by 2%, P = 0.03).
Conclusion
Increasing body weight is associated with significant alterations in RV volumes, energetic, systolic function, and stress responses. Adverse RV modelling is mitigated with weight loss. Randomized trials are needed to determine whether intentional weight loss improves symptoms and outcomes in patients with obesity and heart failure.

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

Eur Heart J Cardiovasc Imaging: 27 Aug 2021; epub ahead of print
Lewis AJM, Abdesselam I, Rayner JJ, Byrne J, ... Neubauer S, Rider OJ
Eur Heart J Cardiovasc Imaging: 27 Aug 2021; epub ahead of print | PMID: 34453521
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Abstract

Novel insights into the athlete\'s heart: is myocardial work the new champion of systolic function?

Tokodi M, Oláh A, Fábián A, Lakatos BK, ... Kovács A, Radovits T
Aims
We sought to investigate the correlation between speckle-tracking echocardiography (STE)-derived myocardial work (MW) and invasively measured contractility in a rat model of athlete\'s heart. We also assessed MW in elite athletes and explored its association with cardiopulmonary exercise test (CPET)-derived aerobic capacity.
Methods and results
Sixteen rats underwent a 12-week swim training program and were compared to controls (n = 16). STE was performed to assess global longitudinal strain (GLS), which was followed by invasive pressure-volume analysis to measure contractility [slope of end-systolic pressure-volume relationship (ESPVR)]. Global MW index (GMWI) was calculated from GLS curves and left ventricular (LV) pressure recordings. In the human investigations, 20 elite swimmers and 20 healthy sedentary controls were enrolled. GMWI was calculated through the simultaneous evaluation of GLS and non-invasively approximated LV pressure curves at rest. All subjects underwent CPET to determine peak oxygen uptake (VO2/kg). Exercised rats exhibited higher values of GLS, GMWI, and ESPVR than controls (-20.9 ± 1.7 vs. -17.6 ± 1.9%, 2745 ± 280 vs. 2119 ± 272 mmHg·%, 3.72 ± 0.72 vs. 2.61 ± 0.40 mmHg/μL, all PExercise < 0.001). GMWI correlated robustly with ESPVR (r = 0.764, P < 0.001). In humans, regular exercise training was associated with decreased GLS (-17.6 ± 1.5 vs. -18.8 ± 0.9%, PExercise = 0.002) but increased values of GMWI at rest (1899 ± 136 vs. 1755 ± 234 mmHg·%, PExercise = 0.025). GMWI exhibited a positive correlation with VO2/kg (r = 0.527, P < 0.001).
Conclusions
GMWI precisely reflected LV contractility in a rat model of exercise-induced LV hypertrophy and captured the supernormal systolic performance in human athletes even at rest. Our findings endorse the utilization of MW analysis in the evaluation of the athlete\'s heart.

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

Eur Heart J Cardiovasc Imaging: 24 Aug 2021; epub ahead of print
Tokodi M, Oláh A, Fábián A, Lakatos BK, ... Kovács A, Radovits T
Eur Heart J Cardiovasc Imaging: 24 Aug 2021; epub ahead of print | PMID: 34432004
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Abstract

Left atrial strain is a predictor of left ventricular systolic and diastolic reverse remodelling in CRT candidates.

Galli E, Oger E, Aalen JM, Duchenne J, ... Smiseth OA, Donal E
Aims
The left atrium (LA) has a pivotal role in cardiac performance and LA deformation is a well-known prognostic predictor in several clinical conditions including heart failure with reduced ejection fraction. The aim of this study is to investigate the effect of cardiac resynchronization therapy (CRT) on both LA morphology and function and to assess the impact of LA reservoir strain (LARS) on left ventricular (LV) systolic and diastolic remodelling after CRT.
Methods and results
Two hundred and twenty-one CRT-candidates were prospectively included in the study in four tertiary centres and underwent echocardiography before CRT-implantation and at 6-month follow-up (FU). CRT-response was defined by a 15% reduction in LV end-systolic volume. LV systolic and diastolic remodelling were defined as the percent reduction in LV end-systolic and end-diastolic volume at FU. Indexed LA volume (LAVI) and LV-global longitudinal (GLS) strain were the main parameters correlated with LARS, with LV-GLS being the strongest determinant of LARS (r = -0.59, P < 0.0001). CRT induced a significant improvement in LAVI and LARS in responders (both P < 0.0001). LARS was an independent predictor of both LV systolic and diastolic remodelling at follow-up (r = -0.14, P = 0.049 and r = -0.17, P = 0.002, respectively).
Conclusion
CRT induces a significant improvement in LAVI and LARS in responders. In CRT candidates, the evaluation of LARS before CRT delivery is an independent predictor of LV systolic and diastolic remodelling at FU.

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

Eur Heart J Cardiovasc Imaging: 24 Aug 2021; epub ahead of print
Galli E, Oger E, Aalen JM, Duchenne J, ... Smiseth OA, Donal E
Eur Heart J Cardiovasc Imaging: 24 Aug 2021; epub ahead of print | PMID: 34432006
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Abstract

Prognostic implications of left heart diastolic dysfunction in adults with coarctation of aorta.

Egbe AC, Miranda WR, Oh JK, Connolly HM
Aims
The prognostic implication of left atrial (LA) dysfunction and left ventricular diastolic dysfunction (LVDD) in patients with coarctation of aorta (COA) is unknown. The purpose of this study was to determine whether LA dysfunction and LVDD were associated with mortality in COA patients.
Methods and results
This is a retrospective review of adults (age ≥18 years) with repaired COA that underwent transthoracic echocardiogram (2000-18). LVDD was determined using the 2016 guidelines for LV diastolic function assessment, and LA dysfunction was assessed using LA reservoir strain. Of 721 patients, LV diastolic function could be determined in 635 (88%); and 414 (65%) had no LVDD, while 146 (23%), 53 (8%), and 22 (4%) had Grade I/II/III LVDD, respectively. The mean LA reservoir strain was 39 ± 11%, and patients were divided into quartiles: top quartile (reference group), mild LA dysfunction, moderate LA dysfunction, and severe LA dysfunction. Grade III LVDD (but not Grades I and II) was associated with death/transplant. On the other hand, there was an incremental risk of death/transplant across LA strain quartiles: mild LA dysfunction [hazard ratio (HR) 1.16, 1.04-2.06], moderate LA dysfunction (HR 1.75, 1.27-3.58), and severe LA dysfunction (HR 3.49, 1.88-7.16). Of 86 patients with indeterminate diastolic function, there was a trend towards a lower 5-year transplant-free survival in patients with LA dysfunction vs. normal LA function (83% vs. 91%, P = 0.06).
Conclusion
LA dysfunction (but not LVDD) was associated with incremental risk of mortality and thus can be used for prognostication in all patients including those with indeterminate diastolic function.

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

Eur Heart J Cardiovasc Imaging: 22 Aug 2021; epub ahead of print
Egbe AC, Miranda WR, Oh JK, Connolly HM
Eur Heart J Cardiovasc Imaging: 22 Aug 2021; epub ahead of print | PMID: 34423358
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Abstract

Computed Tomography-Based Selection of Transseptal Puncture Site for Percutaneous Left Atrial Appendage Closure.

Fukutomi M, Fuchs A, Bieliauskas G, Wong I, ... Søndergaard L, De Backer O
Background
An inferoposterior transseptal puncture (TSP) is generally recommended for percutaneous left atrial appendage (LAA) closure. However, the LAA is a highly variable anatomical structure; this may impact the preferred TSP site.
Aims
This study aimed to determine the most optimal TSP site for percutaneous LAA closure in different LAA morphologies.
Methods
In this prospective study, 182 patients undergoing percutaneous LAA closure were included. The spatial relationship of the LAA to the fossa ovalis and its consequence for TSP was assessed at pre-procedural cardiac computed tomography (CCT).
Results
Based on CCT analysis, it was predicted that co-axial alignment between delivery sheath and LAA would be obtained by an inferoposterior, -central, or -anterior TSP in 75%, 16% and 8% of cases, respectively. This was also confirmed by procedural LAA angiogram in 175 cases (96%) with &lt;30o angle between delivery sheath and LAA central axis. Multivariate logistic regression analysis identified reverse chicken wing LAA (Odds Ratio (OR) 6.36 [1.85-29.3]; P=0.005) and posterior bending of the proximal LAA (OR 17.2 [3.3-96.2]; P&lt;0.001) as independent predictors of a central or anterior TSP - this to increase the chance of obtaining co-axial alignment between delivery sheath and LAA.
Conclusions
An inferoposterior TSP is recommended in a majority of percutaneous LAA closure procedures in order to obtain co-axial alignment between delivery sheath and LAA. An inferior but more central/anterior TSP should be recommended in case of a reverse chicken wing LAA or posterior bending of the proximal LAA, which occurs in 20-25% of cases.



EuroIntervention: 30 Aug 2021; epub ahead of print
Fukutomi M, Fuchs A, Bieliauskas G, Wong I, ... Søndergaard L, De Backer O
EuroIntervention: 30 Aug 2021; epub ahead of print | PMID: 34483092
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Impact:
Abstract

Prevalence of abnormal cardiovascular magnetic resonance findings in recovered patients from COVID-19: a systematic review and meta-analysis.

Kim JY, Han K, Suh YJ
Background
The prevalence of abnormal cardiovascular magnetic resonance (CMR) findings in recovered coronavirus disease 2019 (COVID-19) patients is unclear. This study aimed to investigate the prevalence of abnormal CMR findings in recovered COVID-19 patients.
Methods
A systematic literature search was performed to identify studies that report the prevalence of abnormal CMR findings in recovered COVID-19 patients. The number of patients with abnormal CMR findings and diagnosis of myocarditis on CMR (based on the Lake Louise criteria) and each abnormal CMR parameter were extracted. Subgroup analyses were performed according to patient characteristics (athletes vs. non-athletes and normal vs. undetermined cardiac enzyme levels). The pooled prevalence and 95% confidence interval (CI) of each CMR finding were calculated. Study heterogeneity was assessed, and meta-regression analysis was performed to investigate factors associated with heterogeneity.
Results
In total, 890 patients from 16 studies were included in the analysis. The pooled prevalence of one or more abnormal CMR findings in recovered COVID-19 patients was 46.4% (95% CI 43.2%-49.7%). The pooled prevalence of myocarditis and late gadolinium enhancement (LGE) was 14.0% (95% CI 11.6%-16.8%) and 20.5% (95% CI 17.7%-23.6%), respectively. Further, heterogeneity was observed (I2 > 50%, p < 0.1). In the subgroup analysis, the pooled prevalence of abnormal CMR findings and myocarditis was higher in non-athletes than in athletes (62.5% vs. 17.1% and 23.9% vs. 2.5%, respectively). Similarly, the pooled prevalence of abnormal CMR findings and LGE was higher in the undetermined than in the normal cardiac enzyme level subgroup (59.4% vs. 35.9% and 45.5% vs. 8.3%, respectively). Being an athlete was a significant independent factor related to heterogeneity in multivariate meta-regression analysis (p < 0.05).
Conclusions
Nearly half of recovered COVID-19 patients exhibited one or more abnormal CMR findings. Athletes and patients with normal cardiac enzyme levels showed a lower prevalence of abnormal CMR findings than non-athletes and patients with undetermined cardiac enzyme levels. Trial registration The study protocol was registered in the PROSPERO database (registration number: CRD42020225234).

© 2021. The Author(s).

J Cardiovasc Magn Reson: 02 Sep 2021; 23:100
Kim JY, Han K, Suh YJ
J Cardiovasc Magn Reson: 02 Sep 2021; 23:100 | PMID: 34479603
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Impact:
Abstract

Aortic valve calcification among elderly males from the general population, associated echocardiographic findings, and clinical implications.

Khurrami L, Møller JE, Lindholt JS, Dahl JS, ... Lambrechtsen J, Diederichsen ACP
Aims
Aortic valve calcification (AVC) detected by non-contrast computed tomography (NCCT) associates with morbidity and mortality in patients with aortic valve stenosis. However, the importance of AVC in the general population is sparsely evaluated. We intend to describe the associations between AVC score on NCCT and echocardiographic findings as left atrial (LA) dilatation, left ventricular (LV) hypertrophy, aortic valve area (AVA), peak velocity, mean gradient, and aortic valve replacement (AVR) in a population with AVC scores ≥300 AU.
Methods and results
Of 10 471 males aged 65-74 years from the Danish Cardiovascular Screening trial (DANCAVAS), participants with AVC score ≥300 AU were invited for transthoracic echocardiography and 828 (77%) of 1075 accepted the invitation. AVC scores were categorized (300-599, 600-799, 800-1199, and ≥1200 AU). AVR was obtained from registries. AVC was significantly associated with a steady increase in LA dilation (10.5%, 16.3%, 15.8%, 19.6%, P = 0.031), LV hypertrophy (3.9%, 6.6%, 8.9%, 10.1%, P = 0.021), peak velocity (1.7, 1.9, 2.1, 2.8 m/s, P = 0001), mean gradient (6, 8, 11, 19 mmHg, P = 0.0001), and a decrease in AVA (2.0, 1.9, 1.7, 1.3 cm2, P = 0.0001). The area under the curve was 0.79, 0.93, and 0.92 for AVA ≤1.5 cm2, peak velocity ≥3.0 m/s, and mean gradient ≥20 mmHg, respectively, and the associated optimal AVC score thresholds were 734, 1081, and 1019 AU. AVC > 1200 AU was associated with AVR (P < 0.0001).
Conclusion
Among males from the background population, increasing AVC scores were associated with LA dilatation, LV hypertrophy, AVA, peak aortic velocity, mean aortic gradient, and AVR.

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

Eur Heart J Cardiovasc Imaging: 06 Sep 2021; epub ahead of print
Khurrami L, Møller JE, Lindholt JS, Dahl JS, ... Lambrechtsen J, Diederichsen ACP
Eur Heart J Cardiovasc Imaging: 06 Sep 2021; epub ahead of print | PMID: 34491310
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Impact:
Abstract

Association of aortic valvular complex calcification burden with procedural and long-term clinical outcomes after transcatheter aortic valve replacement.

Ko E, Kang DY, Ahn JM, Kim TO, ... Park SJ, Park DW
Aims
This study aimed to assess the impact of valvular/subvalvular calcium burden on procedural and long-term outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS).
Methods and results
In this prospective observational cohort study, we included patients with AS undergoing TAVR between March 2010 and December 2019. Calcium burden at baseline was quantified using multidetector computed tomography and the patients were classified into tertile groups according to the amount of calcium. Procedural outcomes [paravalvular leakage (PVL) or permanent pacemaker insertion (PPI)] and 12-month clinical outcomes (composite of death, stroke, or rehospitalization, and all-cause mortality) were assessed. A total of 676 patients (age, 79.8 ± 5.4 years) were analysed. The 30-day rates of moderate or severe PVL (P-for-trend = 0.03) and PPI (P-for-trend = 0.002) proportionally increased with the tertile levels of calcium volume. The 12-month rate of primary composite outcomes was 34.2% in low-tertile, 23.9% in middle-tertile, and 25.8% in high-tertile groups (log-rank P = 0.02). After multivariable adjustment, the risk for primary composite outcomes at 12 months was not significantly different between the tertile groups of calcium volume [reference = low-tertile; middle-tertile, hazard ratio (HR) 0.81; 95% confidence interval (CI) 0.54-1.22; P = 0.31; high-tertile, HR 0.93; 95% CI 0.56-1.57; P = 0.80]. A similar pattern was observed for all-cause mortality.
Conclusion
The rates of PVL and PPI proportionally increased according to the levels of valvular/subvalvular calcium volume, while the adjusted risks for composite outcomes and mortality at 12 months were not significantly different.

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

Eur Heart J Cardiovasc Imaging: 06 Sep 2021; epub ahead of print
Ko E, Kang DY, Ahn JM, Kim TO, ... Park SJ, Park DW
Eur Heart J Cardiovasc Imaging: 06 Sep 2021; epub ahead of print | PMID: 34491331
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Abstract

Comparison of left atrial strain measured by feature tracking computed tomography and speckle tracking echocardiography in patients with aortic stenosis.

Hirasawa K, Kuneman JH, Singh GK, Gegenava T, ... Bax JJ, Delgado V
Aims
Peak left atrial longitudinal strain (PALS) is a marker of the left atrial (LA) reservoir function. Novel feature tracking (FT) software allows assessment of LA strain from multidetector computed tomography (MDCT) data. This study aimed at evaluating the agreement between speckle tracking echocardiography (STE) and FT MDCT for the measurement of PALS in patients with sinus rhythm (SR) and with atrial fibrillation (AF).
Methods and results
The current study included 318 patients (80 ± 7 years, 54% male) with dynamic MDCT data acquired prior to transcatheter aortic valve implantation. PALS was measured by transthoracic echocardiography using STE (PALSecho) and MDCT using dedicated FT software (PALSCT). In the overall population, the median values of PALSecho and PALSCT were 19.0 [interquartile range (IQR) 12.0-25.0] % and 15.3 (IQR 9.2-19.7) %, respectively. High correlation between PALSecho and PALSCT was observed (r = 0.789, P < 0.001) with a mean bias of -3.7%. The correlation between PALSecho and PALSCT was better among patients with SR (N = 258; r = 0.704, P < 0.001) as compared to patients with AF (N = 60; r = 0.622, P < 0.001).
Conclusion
PALSecho and PALSCT showed a good agreement in patients with severe aortic stenosis (AS) regardless of the cardiac rhythm. FT MDCT may be an important adjuvant modality for assessing LA reservoir function in patients with severe AS.

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

Eur Heart J Cardiovasc Imaging: 06 Sep 2021; epub ahead of print
Hirasawa K, Kuneman JH, Singh GK, Gegenava T, ... Bax JJ, Delgado V
Eur Heart J Cardiovasc Imaging: 06 Sep 2021; epub ahead of print | PMID: 34491334
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Abstract

Altered hemodynamics by 4D flow cardiovascular magnetic resonance predict exercise intolerance in repaired coarctation of the aorta: an in vitro study.

Mandell JG, Loke YH, Mass PN, Cleveland V, ... Hibino N, Olivieri LJ
Background
Coarctation of the aorta (CoA) is associated with decreased exercise capacity despite successful repair. Altered flow patterns have been identified due to abnormal aortic arch geometry. Our previous work demonstrated aorta size mismatch to be associated with exercise intolerance in this population. In this study, we studied aortic flow patterns during simulations of exercise in repaired CoA using 4D flow cardiovascular magnetic resonance (CMR) using aortic replicas connected to an in vitro flow pump and correlated findings with exercise stress test results to identify biomarkers of exercise intolerance.
Methods
Patients with CoA repair were retrospectively analyzed after CMR and exercise stress test. Each aorta was manually segmented and 3D printed. Pressure gradient measurements from ascending aorta (AAo) to descending aorta (DAo) and 4D flow CMR were performed during simulations of rest and exercise using a mock circulatory flow loop. Changes in wall shear stress (WSS) and secondary flow formation (vorticity and helicity) from rest to exercise were quantified, as well as estimated DAo Reynolds number. Parameters were correlated with percent predicted peak oxygen consumption (VO2max) and aorta size mismatch (DAAo/DDAo).
Results
Fifteen patients were identified (VO2max 47 to 126% predicted). Pressure gradient did not correlate with VO2max at rest or exercise. VO2max correlated positively with the change in peak vorticity (R = 0.55, p = 0.03), peak helicity (R = 0.54, p = 0.04), peak WSS in the AAo (R = 0.68, p = 0.005) and negatively with peak WSS in the DAo (R = - 0.57, p = 0.03) from rest to exercise. DAAo/DDAo correlated strongly with change in vorticity (R = - 0.38, p = 0.01), helicity (R = - 0.66, p = 0.007), and WSS in the AAo (R = - 0.73, p = 0.002) and DAo (R = 0.58, p = 0.02). Estimated DAo Reynolds number negatively correlated with VO2max for exercise (R = - 0.59, p = 0.02), but not rest (R = - 0.28, p = 0.31). Visualization of streamline patterns demonstrated more secondary flow formation in aortic arches with better exercise capacity, larger DAo, and lower Reynolds number.
Conclusions
There are important associations between secondary flow characteristics and exercise capacity in repaired CoA that are not captured by traditional pressure gradient, likely due to increased turbulence and inefficient flow. These 4D flow CMR parameters are a target of investigation to identify optimal aortic arch geometry and improve long term clinical outcomes after CoA repair.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 05 Sep 2021; 23:99
Mandell JG, Loke YH, Mass PN, Cleveland V, ... Hibino N, Olivieri LJ
J Cardiovasc Magn Reson: 05 Sep 2021; 23:99 | PMID: 34482836
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Impact:
Abstract

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

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

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

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

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

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

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

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1774-1783
Sörensson P, Ekenbäck C, Lundin M, Agewall S, ... Ugander M, Tornvall P
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1774-1783 | PMID: 33865778
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Abstract

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

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

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

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1691-1702
Calle S, Kamoen V, De Buyzere M, De Pooter J, Timmermans F
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1691-1702 | PMID: 33865764
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Abstract

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

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

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

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

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

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

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

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1804-1814
Williams MC, Kwiecinski J, Doris M, McElhinney P, ... Dweck MR, Dey D
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1804-1814 | PMID: 33865779
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Abstract

Cardiovascular magnetic resonance findings in young adult patients with acute myocarditis following mRNA COVID-19 vaccination: a case series.

Patel YR, Louis DW, Atalay M, Agarwal S, Shah NR
Background
Messenger RNA (mRNA) coronavirus disease of 2019 (COVID-19) vaccine are known to cause minor side effects at the injection site and mild global systemic symptoms in first 24-48 h. Recently published case series have reported a possible association between acute myocarditis and COVID-19 vaccination, predominantly in young males.
Methods
We report a case series of 5 young male patients with cardiovascular magnetic resonance (CMR)-confirmed acute myocarditis within 72 h after receiving a dose of an mRNA-based COVID-19 vaccine.
Results
Our case series suggests that myocarditis in this setting is characterized by myocardial edema and late gadolinium enhancement in the lateral wall of the left ventricular (LV) myocardium, reduced global LV longitudinal strain, and preserved LV ejection fraction. All patients in our series remained clinically stable during a relatively short inpatient hospital stay.
Conclusions
In conjunction with other recently published case series and national vaccine safety surveillance data, this case series suggests a possible association between acute myocarditis and COVID-19 vaccination in young males and highlights a potential pattern in accompanying CMR abnormalities.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 08 Sep 2021; 23:101
Patel YR, Louis DW, Atalay M, Agarwal S, Shah NR
J Cardiovasc Magn Reson: 08 Sep 2021; 23:101 | PMID: 34496880
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Abstract

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

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

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

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1832-1842
Bec J, Vela D, Phipps JE, Agung M, ... Buja LM, Marcu L
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1832-1842 | PMID: 33221238
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Abstract

Implementing Coronary Computed Tomography Angiography in the Catheterization Laboratory.

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

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

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1846-1855
Collet C, Sonck J, Leipsic J, Monizzi G, ... Andreini D, De Bruyne B
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1846-1855 | PMID: 33248968
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Abstract

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

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

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

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1819-1828
Hirschfeld CB, Mercuri M, Pascual TNB, Karthikeyan G, ... Einstein AJ, INCAPS Investigators Group
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1819-1828 | PMID: 33454257
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Abstract

Myocardial extracellular volume by T1 mapping: a new marker of arrhythmia in mitral valve prolapse.

Pavon AG, Arangalage D, Pascale P, Hugelshofer S, ... Schwitter J, Monney P
Objectives
We aimed to evaluate the relationship between mitral annular disjunction (MAD) severity and myocardial interstitial fibrosis at the left ventricular (LV) base in patients with mitral valve prolapse (MVP), and to assess the association between severity of interstitial fibrosis and the occurrence of ventricular arrhythmic events.
Background
In MVP, MAD has been associated with myocardial replacement fibrosis and arrhythmia, but the importance of interstitial fibrosis remains unknown.
Methods
In this retrospective study, 30 patients with MVP and MAD (MVP-MAD) underwent cardiovascular magnetic resonance (CMR) with assessment of MAD length, late gadolinium enhancement (LGE), and basal segments myocardial extracellular volume (ECVsyn). The control group included 14 patients with mitral regurgitation (MR) but no MAD (MR-NoMAD) and 10 patients with normal CMR (NoMR-NoMAD). Fifteen MVP-MAD patients underwent 24 h-Holter monitoring.
Results
LGE was observed in 47% of MVP-MAD patients and was absent in all controls. ECVsyn was higher in MVP-MAD (30 ± 3% vs 24 ± 3% MR-NoMAD, p < 0.001 and vs 24 ± 2% NoMR-NoMAD, p < 0.001), even in MVP-MAD patients without LGE (29 ± 3% vs 24 ± 3%, p < 0.001 and vs 24 ± 2%, p < 0.001, respectively). MAD length correlated with ECVsyn (rho = 0.61, p < 0.001), but not with LGE extent. Four patients had history of out-of-hospital cardiac arrest; LGE and ECVsyn were equally performant to identify those high-risk patients, area under the receiver operating characteristic (ROC) curve 0.81 vs 0.83, p = 0.84). Among patients with Holter, 87% had complex ventricular arrhythmia. ECVsyn was above the cut-off value in all while only 53% had LGE.
Conclusion
Increase in ECVsyn, a marker of interstitial fibrosis, occurs in MVP-MAD even in the absence of LGE, and was correlated with MAD length and increased risk of out-of-hospital cardiac arrest. ECV should be includedin the CMR examination of MVP patients in an effort to better assess fibrous remodelling as it may provide additional value beyond the assessment of LGE in the arrhythmic risk stratification.

© 2021. The Author(s).

J Cardiovasc Magn Reson: 12 Sep 2021; 23:102
Pavon AG, Arangalage D, Pascale P, Hugelshofer S, ... Schwitter J, Monney P
J Cardiovasc Magn Reson: 12 Sep 2021; 23:102 | PMID: 34517908
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Abstract

Optimal echocardiographic assessment of myocardial dysfunction for arrhythmic risk stratification in phospholamban mutation carriers.

Taha K, Verstraelen TE, de Brouwer R, de Bruin-Bon RHACM, ... van den Berg MP, Teske AJ
Aims 
Phospholamban (PLN) p.Arg14del mutation carriers are at risk of developing malignant ventricular arrhythmias (VAs) and/or heart failure. Currently, left ventricular ejection fraction (LVEF) plays an important role in risk assessment for VA in these individuals. We aimed to study the incremental prognostic value of left ventricular mechanical dispersion (LVMD) by echocardiographic deformation imaging for prediction of sustained VA in PLN p.Arg14del mutation carriers.
Methods and results
We included 243 PLN p.Arg14del mutation carriers, which were classified into three groups according to the \'45/45\' rule: (i) normal left ventricular (LV) function, defined as preserved LVEF ≥45% with normal LVMD ≤45 ms (n = 139), (ii) mechanical LV dysfunction, defined as preserved LVEF ≥45% with abnormal LVMD >45 ms (n = 63), and (iii) overt LV dysfunction, defined as reduced LVEF <45% (n = 41). During a median follow-up of 3.3 (interquartile range 1.8-6.0) years, sustained VA occurred in 35 individuals. The negative predictive value of having normal LV function at baseline was 99% [95% confidence interval (CI): 92-100%] for developing sustained VA. The positive predictive value of mechanical LV dysfunction was 20% (95% CI: 15-27%). Mechanical LV dysfunction was an independent predictor of sustained VA in multivariable analysis [hazard ratio adjusted for VA history: 20.48 (95% CI: 2.57-162.84)].
Conclusion 
LVMD has incremental prognostic value on top of LVEF in PLN p.Arg14del mutation carriers, particularly in those with preserved LVEF. The \'45/45\' rule is a practical approach to echocardiographic risk stratification in this challenging group of patients. This approach may also have added value in other diseases where LVEF deterioration is a relative late marker of myocardial dysfunction.

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

Eur Heart J Cardiovasc Imaging: 12 Sep 2021; epub ahead of print
Taha K, Verstraelen TE, de Brouwer R, de Bruin-Bon RHACM, ... van den Berg MP, Teske AJ
Eur Heart J Cardiovasc Imaging: 12 Sep 2021; epub ahead of print | PMID: 34516619
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Abstract

Long-Term Neurocognitive Outcome in Patients With Continuous Flow Left Ventricular Assist Device.

Cho SM, Floden D, Wallace K, Hiivala N, ... Mahr C, Uchino K
Objectives
The authors sought to examine the long-term cognitive outcome of patients with continuous flow left ventricular assist device (CF-LVAD).
Background
Data on long-term neurocognitive outcome in LVAD are limited. We examined the neurocognitive outcome of patients who received a CF-LVAD as destination therapy.
Methods
Patients with HeartWare (HVAD) and HeartMate II who were enrolled in the ENDURANCE and ENDURANCE Supplemental trials were eligible. Cognition was evaluated with neuropsychological testing preoperatively and at 6, 12, and 24 months after implantation. General linear models identified demographic, disease, and treatment factors that predicted decline on each neurocognitive measure.
Results
Of 668 patients who completed baseline testing and at least 1 follow-up evaluation, 552 were impaired at baseline on at least 1 cognitive measure. At each follow-up, approximately 23% of tested patients declined and 20% improved relative to baseline on at least 1 cognitive measure. Of those who were intact at baseline, only 10%-12% declined in delayed memory and 11%-16% declined in executive function at all 3 follow-ups. For patients impaired at baseline, delayed memory decline was associated with the HVAD device and male sex, whereas executive function decline was associated with the HVAD device and stroke during CF-LVAD support. For patients intact at baseline, male sex and history of hypertension were associated with decline in immediate memory and executive function, respectively.
Conclusion
Neurocognitive function remained stable or improved for most patients (∼80%) with CF-LVAD at 6, 12, and 24 months after implantation. Male sex, hypertension, HVAD, and stroke were associated with cognitive decline.

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

JACC Heart Fail: 31 Aug 2021; epub ahead of print
Cho SM, Floden D, Wallace K, Hiivala N, ... Mahr C, Uchino K
JACC Heart Fail: 31 Aug 2021; epub ahead of print | PMID: 34509403
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Abstract

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

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

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

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

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

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

Copyright © 2021. Published by Elsevier Inc.

JACC Cardiovasc Imaging: 30 Aug 2021; 14:1724-1737
Amanullah MR, Pio SM, Ng ACT, Sin KYK, ... Ewe SH, Bax JJ
JACC Cardiovasc Imaging: 30 Aug 2021; 14:1724-1737 | PMID: 34023268
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Impact:

This program is still in alpha version.