Topic: Imaging

Abstract

Association Between Left Ventricular Noncompaction and Vigorous Physical Activity.

de la Chica JA, Gómez-Talavera S, García-Ruiz JM, García-Lunar I, ... Ibáñez B, Fuster V
Background
Left ventricular (LV) hypertrabeculation fulfilling noncompaction cardiomyopathy criteria has been detected in athletes. However, the association between LV noncompaction (LVNC) phenotype and vigorous physical activity (VPA) in the general population is disputed.
Objectives
The aim of this study was to assess the relationship between LVNC phenotype on cardiac magnetic resonance (CMR) imaging and accelerometer-measured physical activity (PA) in a cohort of middle-aged nonathlete participants in the PESA (Progression of Early Subclinical Atherosclerosis) study.
Methods
In PESA participants (n = 4,184 subjects free of cardiovascular disease), PA was measured by waist-secured accelerometers. CMR was performed in 705 subjects (mean age 48 ± 4 years, 16% women). VPA was recorded as total minutes per week. The study population was divided into 6 groups: no VPA and 5 sex-specific quintiles of VPA rate (Q1 to Q5). The Petersen criterion for LVNC was evaluated in all subjects undergoing CMR. For participants meeting this criterion (noncompacted-to-compacted ratio ≥2.3), 3 more restrictive LVNC criteria were also evaluated (Jacquier, Grothoff, and Stacey).
Results
LVNC phenotype prevalence according to the Petersen criterion was significantly higher among participants in the highest VPA quintile (Q5 = 30.5%) than in participants with no VPA (14.2%). The Jacquier and Grothoff criteria were also more frequently fulfilled in participants in the highest VPA quintile (Jacquier Q5 = 27.4% vs. no VPA = 12.8% and Grothoff Q5 = 15.8% vs. no VPA = 7.1%). The prevalence of the systolic Stacey LVNC criterion was low (3.6%) and did not differ significantly between no VPA and Q5.
Conclusions
In a community-based study, VPA was associated with a higher prevalence of CMR-detected LVNC phenotype according to diverse established criteria. The association between VPA and LVNC phenotype was independent of LV volumes. According to these data, vigorous recreational PA should be considered as a possible but not uncommon determinant of LV hypertrabeculation in asymptomatic subjects.

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

J Am Coll Cardiol: 12 Oct 2020; 76:1723-1733
de la Chica JA, Gómez-Talavera S, García-Ruiz JM, García-Lunar I, ... Ibáñez B, Fuster V
J Am Coll Cardiol: 12 Oct 2020; 76:1723-1733 | PMID: 33032733
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Abstract

Impact of different dipping patterns on left atrial function in hypertension.

Tadic M, Cuspidi C, Pencic B, Mancia G, ... Quarti-Trevano F, Celic V
Objective
We aimed to investigate left atrial phasic function in the recently diagnosed hypertensive patients and determine association between circadian blood pressure (BP) patterns and left atrial function.
Methods
The present study involved 256 untreated hypertensive patients who underwent 24-h ambulatory BP monitoring and comprehensive echocardiographic examination. All patients were divided into four groups according to the percentage of nocturnal BP drop (dippers, extreme dippers, nondippers and reverse dippers).
Results
There was no significant difference in daytime BPs between the observed groups, whereas night-time BPs significantly and gradually increased from extreme dippers and dippers, across nondippers, to reverse dippers. Total, passive and active left atrial emptying fractions that correspond with left atrial reservoir, conduit and contractile function were lower in nondippers and reverse dippers than in dippers and extreme dippers. Reservoir and contractile left atrial strains were lower in reverse dippers than in dippers and extreme dippers, whereas conduit left atrial strain was lower in reverse dippers in comparison with extreme dippers. Nondipping and reverse dipping BP patterns were, independently of age, sex, nocturnal BPs, left ventricular mass index, E/e\', associated with reduced reservoir function. Nevertheless, only reverse dipping profile was independently of other circadian BP profiles, nocturnal BP, demographic and echocardiographic parameters related with reduced conduit and contractile functions.
Conclusion
Nondipping and reverse dipping BP patterns were related with impaired left atrial phasic function. However, reverse pattern was the only circadian profile that was independently of other clinical parameters, including night-time BP, associated with decreased reservoir, conduit and contractile function.



J Hypertens: 30 Oct 2020; 38:2245-2251
Tadic M, Cuspidi C, Pencic B, Mancia G, ... Quarti-Trevano F, Celic V
J Hypertens: 30 Oct 2020; 38:2245-2251 | PMID: 32649632
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Abstract

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

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



J Hypertens: 05 Oct 2020; epub ahead of print
Jiang L, Ren Y, Yu H, Guo YK, ... Han PL, Yang ZG
J Hypertens: 05 Oct 2020; epub ahead of print | PMID: 33031176
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Abstract

Improvement of the Prognosis Assessment of Severe Tricuspid Regurgitation by the Use of a Five-Grade Classification of Severity.

Peugnet F, Bohbot Y, Chadha G, Delpierre Q, ... Beyls C, Tribouilloy C

It is well known that some patients present with \"more than severe\" tricuspid regurgitation (TR). We aimed to assess the prognosis of these very severe TR patients. We defined very severe TR using 3 simple echocardiographic parameters: a coaptation gap≥10mm, a laminar TR flow and a systolic reversal of the hepatic vein flow. We included 259 consecutive patients (76 ± 13 years; 46% men) with moderate-to-severe TR (n = 114) and severe TR (n = 145). The primary end point was the combination of hospitalisation for right heart failure (RHF) and cardiovascular mortality. Median follow-up was 24(7 to 47) months. In patients with severe TR, 52 (36%) met the definition of very severe TR. These patients were younger, had more history of RHF and were more frequently treated with loop diuretics than those with moderate-to-severe TR (all p < 0.001). Four-year event-free survival rates were 68 ± 5%, for moderate-to-severe TR, 48 ± 6% for severe TR and only 35 ± 7% for very-severe TR (p < 0.001). On multivariable analysis, after adjustment for outcome predictors including age, comorbidity, RHF, TR etiology, left and right ventricular dysfunction, and tricuspid valve surgery, patients with very severe TR had a worsened prognosis than those with moderate-to-severe TR (Adjusted Hazard Ratio [95% Confidence Interval] = 2.43 [1.18 to 5.53]; p = 0.002) and than those with severe TR (Adjusted Hazard Ratio [95% Confidence Interval] = 2.23 [1.06 to 5.56]; p = 0.015). In conclusion, very severe TR is frequent in patients with severe TR, corresponds to a more advanced stage of the disease and is associated with poor outcomes. Therefore, the use of a 5-grade classification of TR severity is justified in routine clinical practice. (ID-RCB: 2017-A03233-50).

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2020; 132:119-125
Peugnet F, Bohbot Y, Chadha G, Delpierre Q, ... Beyls C, Tribouilloy C
Am J Cardiol: 30 Sep 2020; 132:119-125 | PMID: 32741538
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Abstract

Ventricular Septal Myectomy for the Treatment of Left Ventricular Outflow Tract Obstruction Due to Fabry Disease.

Raju B, Roberts CS, Sathyamoorthy M, Schiffman R, Swift C, McCullough PA

Fabry cardiomyopathy can cause symptomatic left ventricular outflow tract obstruction. We review a case of Fabry cardiomyopathy mimicking hypertrophic cardiomyopathy on echocardiography with severe left ventricular outflow tract obstruction treated with ventricular septal myectomy.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2020; 132:160-164
Raju B, Roberts CS, Sathyamoorthy M, Schiffman R, Swift C, McCullough PA
Am J Cardiol: 30 Sep 2020; 132:160-164 | PMID: 32773220
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Abstract

Predicting the Development of Reduced Left Ventricular Ejection Fraction in Patients with Left Bundle Branch Block.

Atwater BD, Emerek K, Samad Z, Sze E, ... Søgaard P, Friedman DJ

Left bundle branch block (LBBB) increases the likelihood of developing reduced left ventricular (LV) ejection fraction (EF) but predicting which patients with LBBB and normal LVEF will develop decreased LVEF remains challenging. Fifty patients with LBBB and normal LVEF were retrospectively identified. Clinical, electrocardiographic (ECG), and echocardiographic variables were compared between patients who developed a decreased LVEF and those who did not. A total of 16/50 patients developed reduced LVEF after 4.3 (SD=2.8) years of follow-up. Baseline patient and ECG variables were similar between patients who did and did not develop decreased LVEF. Baseline LVEF was lower in patients who developed decreased LVEF than in those who did not [51.9% (SD=2.2%) vs. 54.9% (SD=4.4%), P<0.01.] Diastolic filling time (DFT) accounted for a significantly smaller percentage of the cardiac cycle in patients who developed decreased LVEF than in those who did not [35.9%, (SD=6.9%) vs. 44.4% (SD=4.5%) P<0.01]. In univariable logistic regression, DFT had a C-statistic of 0.86 (P<0.0001) for prediction of development of decreased LVEF. In conclusion, patients in whom DFT accounted for <38% of the cardiac cycle had a relative risk of developing decreased LVEF of 7.0 (95% CI 3.0-16.0) compared to patients with DFT accounting for ≥38% of the cardiac cycle.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 26 Sep 2020; epub ahead of print
Atwater BD, Emerek K, Samad Z, Sze E, ... Søgaard P, Friedman DJ
Am J Cardiol: 26 Sep 2020; epub ahead of print | PMID: 32998010
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Abstract

Effect of Progression of Valvular Calcification on Left Ventricular Structure and Frequency of Incident Heart Failure (from the Multiethnic Study of Atherosclerosis).

Fashanu OE, Upadhrasta S, Zhao D, Budoff MJ, ... Lima JAC, Michos ED

Heart failure (HF) is a leading cause of morbidity. Strategies for preventing HF are paramount. Prevalent extracoronary calcification is associated with HF risk but less is known about progression of mitral annular (MAC) and aortic valve calcification (AVC) and HF risk. Progression of valvular calcification (VC) [interval change of >0 units/yr] was assessed by 2 cardiac computed tomography scans over a median of 2.4 years. We used Cox regression to determine the risk of adjudicated HF and linear mixed effects models to determine 10-year change in left ventricular (LV) parameters measured by cardiac magnetic resonance imaging associated with VC progression. We studied 5,591 MESA participants free of baseline cardiovascular disease. Mean ± SD age was 62 ± 10 years; 53% women; 83% had no VC progression, 15% progressed at 1 site (AVC or MAC) and 3% at both sites. There were 251 incident HF over 15 years. After adjusting for cardiovascular risk factors, the hazard ratios (95% confidence interval) of HF associated with VC progression at 1 and 2 sites were 1.62 (1.21 to 2.17) and 1.88 (1.14 to 3.09), respectively, compared with no progression (p-for-trend <0.001). Hazard ratios were higher for HFpEF (2.52 [1.63 to 3.90] and 2.49 [1.19 to 5.25]) but nonsignificant for HFrEF. Both AVC (1.61 [1.19 to 2.19]) and MAC (1.50 [1.09 to 2.07]) progression were associated with HF. VC was associated with worsening of some LV parameters over 10 years. In conclusion, VC progression was associated with increased risk of HF and change in LV function. Interventions targeted at reducing VC progression may also impact HF risk, particularly HFpEF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:99-107
Fashanu OE, Upadhrasta S, Zhao D, Budoff MJ, ... Lima JAC, Michos ED
Am J Cardiol: 31 Oct 2020; 134:99-107 | PMID: 32917344
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Abstract

Utility of Cardiac Magnetic Resonance Imaging Versus Cardiac Positron Emission Tomography for Risk Stratification for Ventricular Arrhythmias in Patients With Cardiac Sarcoidosis.

Gowani Z, Habibi M, Okada DR, Smith J, ... Tandri H, Chrispin J

Abnormalities on cardiac magnetic resonance imaging (CMR) and positron emission tomography (PET) predict ventricular arrhythmias (VA) in patients with cardiac sarcoidosis (CS). Little is known whether concurrent abnormalities on CMR and PET increases the risk of developing VA. Our aim was to compare the additive utility of CMR and PET in predicting VA in patients with CS. We included all patients treated at our institution from 2000 to 2018 who (1) had probable or definite CS and (2) had undergone both CMR and PET. The primary endpoint was VA at follow up, which was defined as sustained ventricular tachycardia, sudden cardiac death, or any appropriate device tachytherapy. Fifty patients were included, 88% of whom had a left ventricular ejection fraction >35%. During a mean follow-up 4.1 years, 7/50 (14%) patients had VA. The negative predictive value of LGE for VA was 100% and the negative predictive value of FDG for VA was 79%. Among groups, VA occurred in 4/21 (19%) subjects in the LGE+/FDG+ group, 3/14 (21%) in the LGE+/FDG- group, and 0/15 (0%) in the FDG+/LGE- group. There were no LGE-/FDG- patients. In conclusion, CMR may be the preferred initial clinical risk stratification tool in patients with CS. FDG uptake without LGE on initial imaging may not add additional prognostic information regarding VA risk.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 31 Oct 2020; 134:123-129
Gowani Z, Habibi M, Okada DR, Smith J, ... Tandri H, Chrispin J
Am J Cardiol: 31 Oct 2020; 134:123-129 | PMID: 32950203
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Abstract

Comparison of the Usefulness of Strain Imaging by Echocardiography Versus Computed Tomography to Detect Right Ventricular Systolic Dysfunction in Patients With Significant Secondary Tricuspid Regurgitation.

Hirasawa K, van Rosendael PJ, Dietz MF, Ajmone Marsan N, Delgado V, Bax JJ

Assessment of right ventricular (RV) systolic function in patients with significant secondary tricuspid regurgitation (STR) remains challenging. In patients with severe aortic stenosis treated with transcatheter aortic valve implantation (TAVI), STR and RV enlargement have been associated with poor outcomes. In these patients, speckle tracking echocardiography (STE) may detect RV systolic dysfunction better than 3-dimensional (3D) RV ejection fraction (EF). The purpose of this study was to investigate the prevalence of RV dysfunction when assessed with STE in patients with significant STR (≥3+) compared with patients without significant STR (<3+) matched for 3D RV dimensions and RVEF on dynamic computed tomography (CT). Patients with dynamic CT data before TAVI were evaluated retrospectively. To assess the performance of RV-free wall strain (RVFWS) for identifying patients with impaired RV systolic function, patients were subsequently matched 1:1 based on age, gender, indexed RV end-diastolic volume (RVEDVi), indexed RV end-systolic volume (RVESVi), RVEF, and left ventricular ejection fraction (LVEF). In a total 267 patients (80 ± 8 years, 48% male), significant STR (≥3+) was observed in 67 patients. Patients with STR≥3+ had larger RVEDVi, larger RVESVi, lower LVEF, and more impaired RVFWS compared with patients with STR<3+ (n = 200). After propensity score matching, patients with STR≥3+ (n = 53) had significantly more impaired RVFWS compared with patients with STR<3+ (n = 53): -18.2 ± 5.0% versus -21.1 ± 3.7%, p = 0.001. In conclusion, patients with significant STR have more pronounced RV systolic dysfunction as assessed with STE than the patients without significant STR despite having similar 3D RV dimensions and RVEF on dynamic CT.

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

Am J Cardiol: 31 Oct 2020; 134:116-122
Hirasawa K, van Rosendael PJ, Dietz MF, Ajmone Marsan N, Delgado V, Bax JJ
Am J Cardiol: 31 Oct 2020; 134:116-122 | PMID: 32891401
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Abstract

Prominent Longitudinal Strain Reduction of Basal Left Ventricular Segments in Patients with COVID-19.

Goerlich E, Gilotra NA, Minhas AS, Bavaro N, Hays AG, Cingolani OH
Background
COVID-19 has been associated with overt and subclinical myocardial dysfunction. We observed a recurring pattern of reduced basal left ventricular (LV) longitudinal strain (LS) on speckle-tracking echocardiography (STE) in hospitalized COVID-19 patients and subsequently aimed to identify characteristics of affected patients. We hypothesized that COVID-19 patients with reduced basal LV strain would demonstrate elevated cardiac biomarkers.
Methods
81 consecutive COVID-19 patients underwent STE. Those with poor quality STE (n=2) or known LV ejection fraction<50% (n=4) were excluded. Patients with absolute value basal LS<13.9% (2SD below normal) were designated as cases (n=39); those with basal LS≥13.9% as controls (n=36). Demographics and clinical variables were compared.
Results
Of 75 included patients (mean age 62±14 years, 41% women), 52% had reduced basal strain. Cases had higher BMI (median[IQR]) (34.1[26.5-37.9]kg/m vs. 26.9[24.8-30.0]kg/m, p=0.009), and greater proportions of Black (74% vs. 36%, p=0.0009), hypertensive (79% vs. 56%, p=0.026) and diabetic patients (44% vs. 19%, p=0.025) compared to controls. Troponin and NT-proBNP levels trended higher in cases but were not significantly different.
Conclusions and relevance
Reduced basal LV strain is common in COVID-19 patients. Patients with hypertension, diabetes, obesity, and Black race were more likely to have reduced basal strain. Further investigation into the significance of this strain pattern is warranted.

Copyright © 2020. Published by Elsevier Inc.

J Card Fail: 25 Sep 2020; epub ahead of print
Goerlich E, Gilotra NA, Minhas AS, Bavaro N, Hays AG, Cingolani OH
J Card Fail: 25 Sep 2020; epub ahead of print | PMID: 32991982
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Abstract

Left Atrial Strain in Evaluation of Heart Failure with Preserved Ejection Fraction.

Ye Z, Miranda WR, Yeung DF, Kane GC, Oh JK
Background
Patients with heart failure with preserved ejection fraction (HFpEF) may have elevated left ventricular filling pressure with exercise (LVFP-ex), despite normal LVFP at rest. The aim of this study was to assess the diagnostic value of resting left atrial strain (LAS) in detecting elevated LVFP-ex in patients with dyspnea evaluated on exercise stress echocardiography.
Methods
Two-dimensional speckle-tracking analysis for LAS was performed in 669 consecutive patients (mean age, 64 ± 14 years; 53% men) who underwent treadmill echocardiographic evaluation and had left ventricular ejection fractions ≥ 50%. Assessment of LVFP at rest LVFP-ex was based on the 2016 American Society of Echocardiography guidelines for diastolic function assessment. An E/e\' ratio ≥ 15 after exercise is considered to indicate elevated LVFP-ex. A continuous diagnostic score of HFpEF was calculated on the basis of the European Society of Cardiology HFA-PEFF diagnostic algorithm.
Results
LAS was lowest in patients with elevated LVFP at rest (n = 81) and lower in those with normal resting filling pressure who developed elevated LVFP-ex (n = 108) compared with those who maintained normal LVFP-ex (29.0 ± 5.2% vs 33.1 ± 5.0% vs 39.3 ± 4.8%, P < .001). Lower LAS was associated with worse exercise capacity as assessed by metabolic equivalents, exercise time, and functional aerobic capacity (multivariate-adjusted P values all < .05). In patients with normal or indeterminate LVFP at rest (n = 587), LAS and preexercise HFA-PEFF score demonstrated areas under the curve of 0.82 and 0.7, respectively, for elevated LVFP-ex. There were 28% higher odds of developing elevated LVFP-ex per 1% decrease in LAS (odds ratio, 0.78; 95% CI, 0.74-0.82). Among patients with intermediate scores (n = 461), 123 developed elevations in LVFP-ex and were classified as having HFpEF per the diagnostic algorithm. The addition of LAS improved the diagnostic value of HFA-PEFF score for HFpEF (area under the curve increased from 0.71 to 0.80, P = .01).
Conclusions
LAS has potential to identify patients with intermediate scores for HFpEF who may develop elevated LVFP-ex only and is therefore a promising alternative to aid in diagnosis when exercise testing is not feasible.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print
Ye Z, Miranda WR, Yeung DF, Kane GC, Oh JK
J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print | PMID: 32981787
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Abstract

Evaluation of the right heart using cardiovascular magnetic resonance imaging in patients with cardiac devices.

Löbe S, Paetsch I, Hilbert S, Spampinato R, ... Hindricks G, Jahnke C
Background
Patients with cardiac implantable electronic devices (CIED) necessitate comprehensive cardiovascular magnetic resonance (CMR) examinations. The aim of this study was to provide data on CMR image quality and feasibility of functional assessment of the right heart in patients with CIED depending on the device type and imaging sequence used.
Methods
120 CIED carriers (Insertable cardiac monitoring system, n = 13; implantable loop-recorder, n = 22; pacemaker, n = 30; implantable cardioverter-defibrillator (ICD), n = 43; and cardiac resynchronization therapy defibrillator (CRT-D), n = 12) underwent clinically indicated CMR imaging using a 1.5 T. CMR protocols consisted of cine imaging and myocardial tissue characterization including T1-and T2-weighted blackblood imaging and late gadolinium enhancement (LGE) imaging. Image quality was evaluated with regard to device-related imaging artifacts per right-ventricular (RV) segment.
Results
RV segmental evaluability was influenced by the device type and CMR imaging sequence: Cine steady-state-free-precision (SSFP) imaging was found to be non-diagnostic in patients with ICD/CRT-D and implantable loop recorders; a significant improvement of image quality was achieved when using cine turbo-field-echo (TFE) sequences with a further improvement on post-contrast TFE imaging. LGE scans were artifact-free in at least 91% of RV segments with best results in patients with a pacemaker or an insertable cardiac monitoring system.
Conclusions
In patients with CIED, artifact-free CMR imaging of the right ventricle was performed in the majority of patients and resulted in highly reproducible evaluability of RV functional parameters. This finding is of particular importance for the diagnosis and follow-up of right-ventricular diseases.

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

Int J Cardiol: 30 Sep 2020; 316:266-271
Löbe S, Paetsch I, Hilbert S, Spampinato R, ... Hindricks G, Jahnke C
Int J Cardiol: 30 Sep 2020; 316:266-271 | PMID: 32389768
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Abstract

Improved Delineation of Cardiac Pathology Using a Novel Three-Dimensional Echocardiographic Tissue Transparency Tool.

Karagodin I, Addetia K, Singh A, Dow A, ... Mor-Avi V, Lang RM
Background
Accurate visualization of cardiac valves and lesions by three-dimensional (3D) echocardiography is integral for optimal guidance of structural procedures and appropriate selection of closure devices. A new 3D rendering tool known as transillumination (TI), which integrates a virtual light source into the data set, was recently reported to effectively enhance depth perception and orifice definition. We hypothesized that adding the ability to adjust transparency to this tool would result in improved visualization and delineation of anatomy and pathology and improved localization of regurgitant jets compared with TI without transparency and standard 3D rendering.
Methods
We prospectively studied 30 patients with a spectrum of structural heart disease who underwent 3D transesophageal imaging (EPIQ system, Philips) with standard acquisition and TI with and without the transparency feature. Six experienced cardiologists and sonographers were shown randomized images of all three display types in a blinded fashion. Each image was scored independently by all experts using a Likert scale from 1 to 5, while assessing each of the following aspects: (1) ability to recognize anatomy, (2) ability to identify pathology, including regurgitant jet origin, (3) depth perception, and (4) quality of border delineation.
Results
TI images with transparency were successfully obtained in all cases. All experts perceived an incremental value of the transparency mode, compared with TI without transparency and standard 3D rendering, in terms of ability to recognize anatomy (respective scores: 4.5 ± 1.1 vs 4.1 ± 1.1 vs 3.6 ± 1.1, P < .05), ability to identify pathology (4.1 ± 1.1 vs 3.9 ± 1.2 vs 3.3 ± 1, P < .05), depth perception (4.6 ± 0.7 vs 4.1 ± 0.8 vs 3.2 ± 1.0, P < .05), and border delineation (4.6 ± 0.8 vs 4.1 ± 1.0 vs 3.1 ± 1.1, P < .05).
Conclusions
The addition of the transparency mode to TI rendering significantly improves the diagnostic and clinical utility of 3D echocardiography and has the potential to markedly enhance echocardiographic guidance of cardiac structural interventions.

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

J Am Soc Echocardiogr: 20 Sep 2020; epub ahead of print
Karagodin I, Addetia K, Singh A, Dow A, ... Mor-Avi V, Lang RM
J Am Soc Echocardiogr: 20 Sep 2020; epub ahead of print | PMID: 32972777
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Abstract

Accuracy of contrast-enhanced computed tomography for thrombus detection prior to atrial fibrillation ablation and role of novel Left Atrial Appendage Enhancement Index in appendage flow assessment.

Guha A, Dunleavy MP, Hayes S, Afzal MR, ... Raman SV, Harfi TT
Aims
To evaluate diagnostic accuracy of different protocols of contrast enhanced computed tomography venogram (CTV) for LAA thrombus detection in patients undergoing AF ablation and study the correlation of the novel LAA enhancement index (LAA-EI) to LAA flow velocity obtained using transesophageal echocardiography (TEE).
Methods
Study comprised of patients undergoing CTV and TEE on the same day from October 2016 to December 2017. Three CTV scanning protocols (described in results), were evaluated wherein ECG gating was used only for those with sinus rhythm on day of CTV. LAA-EI was calculated as Hounsfield Unit (HU) in the LAA divided by the HU unit in the center of the LA. The diagnostic accuracy for CTV was calculated in comparison to TEE. The LAA-EI was compared to LAA emptying velocities as obtained from TEE.
Results
590 patients with 45.6% non-ECG-gated without delayed imaging, 26.9% non-ECG-gated with delayed imaging and 27.5% ECG-gated with delayed imaging, were included in the study. All three protocols had 100% negative predictive value with improvement in specificity from 61.8% to 98.1% upon adding delayed imaging. The LAA-EI correlated significantly with reduced LAA flow velocities (r = 0.45, p < .0001). The mean LAA emptying velocity in patients with LAA-EI of ≤ 0.6 was significantly lower than in those with LAA-EI of >0.6 (36.2 cm/s [95% CI: 32.6-39.7] vs, (58 cm/s [95% CI 55.3-60.8]), respectively (p < .0001).
Conclusion
CTV with delayed imaging (with or without ECG gating) is highly specific in ruling out LAA thrombus. The novel LAA-EI can detect low LAA flow velocities.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 31 Oct 2020; 318:147-152
Guha A, Dunleavy MP, Hayes S, Afzal MR, ... Raman SV, Harfi TT
Int J Cardiol: 31 Oct 2020; 318:147-152 | PMID: 32629004
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Abstract

Diagnostic Performance of Transesophageal Echocardiography and Cardiac Computed Tomography in Infective Endocarditis.

Sifaoui I, Oliver L, Tacher V, Fiore A, ... Ternacle J, Deux JF
Background
Multimodality imaging is essential for infective endocarditis (IE) diagnosis. The aim of this work was to evaluate the agreement between transesophageal echocardiography (TEE) and cardiac computed tomography (CT) findings in patients with surgically confirmed IE.
Methods
Sixty-eight patients (mean age 63 ± 2 years) with a definite diagnosis of left-side IE according to the modified European Society of Cardiology Duke criteria, on both native and prosthetic valves, underwent TEE and cardiac CT before surgery. The presence of valvular (vegetations, erosion) and paravalvular (abscess, pseudoaneurysm) IE-related lesions were compared between both modalities. Perioperative inspection was used as reference.
Results
TEE performed better than CT in detecting valvular IE-related lesions (TEE area under the curve [AUC] = 0.881 vs AUC = 0.720, P = .02) and was similar to CT with respect to paravalvular IE-related lesions (AUC = 0.830 vs AUC = 0.816, P = .835). The ability of TEE to detect vegetation was significantly better than that of CT (AUC = 0.863 vs AUC = 0.693, P = .02). The maximum size of vegetations was moderately correlated between modalities (Spearman\'s rho = 0.575, P < .001). Computed tomography exhibited higher sensitivity than TEE for pseudoaneurysm detection (100% vs 66.7%, respectively) but was similar with respect to diagnostic accuracy (AUC = 0.833 vs AUC = 0.984, P = .156).
Conclusions
In patients with a definite diagnosis of left-side IE according to the modified European Society of Cardiology Duke criteria, TEE performed better than CT for the detection of valvular IE-related lesions and similar to CT for the detection of paravalvular IE-related lesions.

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

J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print
Sifaoui I, Oliver L, Tacher V, Fiore A, ... Ternacle J, Deux JF
J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print | PMID: 32981789
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Impact:
Abstract

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

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

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 27 Sep 2020; epub ahead of print
He H, Datla S, Weight N, Raza S, ... Hayat S, Osman F
Int J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 33002522
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Impact:
Abstract

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

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

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 06 Oct 2020; epub ahead of print
Fu H, Wen L, Xu H, Liu H, ... Yang Z, Guo Y
Int J Cardiol: 06 Oct 2020; epub ahead of print | PMID: 33038407
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Impact:
Abstract

The Prognostic Value of Exercise Echocardiography after Percutaneous Coronary Intervention.

Marques A, Cruz I, João I, Almeida AR, ... Lopes LR, Pereira H
Background
Exercise echocardiography (EE) is a valuable noninvasive method for diagnostic and prognostic assessment of ischemic cardiac disease. The prognostic value of normal findings on EE is well known overall, but its role in patients who undergo percutaneous coronary intervention remains poorly validated. The aim of this study was to ascertain the prognostic value of treadmill EE and to determine predictors of cardiac events in this population, with an emphasis on nonpositive (negative or inconclusive) findings.
Methods
A retrospective single-center study was performed. It included 516 patients (83% man; mean age, 62 ± 9 years) previously subjected to percutaneous coronary intervention who underwent treadmill EE between 2008 and 2017. Demographic, clinical, echocardiographic, and angiographic data were collected. The occurrence of cardiac events (cardiac death, acute coronary syndrome, or coronary revascularization) during follow-up was investigated. A multivariate Cox regression analysis was used to evaluate predictors of cardiac events. The Kaplan-Meier method was used to evaluate event-free survival rates.
Results
The results of EE were negative for myocardial ischemia in 245 patients (47.5%), inconclusive in 144 (27.9%), and positive in 127 (24.6%). During a mean follow-up period of 40 ± 34 months, cardiac events occurred in 152 patients (29.5%). The positive and negative predictive values of EE were 81.6% and 85.3%, respectively. The sensitivity of the exercise test was 73.9%, with specificity of 90.1%. Predictors of cardiac events were typical angina (hazard ratio [HR], 1.95; 95% CI, 1.16-3.27; P = .011), a positive ischemic response detected by electrocardiographic monitoring during EE (HR, 2.01; 95% CI, 1.21-3.34; P = .007), and the test result (inconclusive result: HR, 1.06; 95% CI, 0.51-2.19; P = .878; positive result: HR, 4.35; 95% CI, 2.42-7.80; P < .001). Patients with inconclusive (log-rank P = .038) and positive (log-rank P < .001) results had significantly more cardiac events during follow-up than those with negative findings on EE. Focusing on those patients with nonpositive results, cardiac event-free survival rates at 1, 3, and 5 years were 96.6 ± 0.9%, 88.3 ± 1.9%, and 79.5 ± 2.6%, respectively. In this subpopulation, an inconclusive test result (HR, 1.67; 95% CI, 1.03-2.70; P = .039), more extensive coronary artery disease (two vessels: HR, 1.37; 95% CI, 0.75-2.30; P = .304; three vessels: HR, 2.59; 95% CI, 1.38-4.87; P = .003), and arterial hypertension (HR, 2.07; 95% CI, 1.10-3.91; P = .025) were significantly associated with the occurrence of cardiac events.
Conclusion
Patients with known coronary disease with negative results on EE are at low risk for hard events. Patients with inconclusive results are at higher risk for cardiac events than those with negative results. The detection of patients with low-risk results on EE should decrease the number of unnecessary repeat invasive coronary angiographic examinations.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print
Marques A, Cruz I, João I, Almeida AR, ... Lopes LR, Pereira H
J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print | PMID: 33036819
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Impact:
Abstract

Usefulness of Noninvasive Myocardial Work to Predict Left Ventricular Recovery and Acute Complications after Acute Anterior Myocardial Infarction Treated by Percutaneous Coronary Intervention.

Meimoun P, Abdani S, Stracchi V, Elmkies F, ... Zemir H, Clerc J
Background
Predicting left ventricular recovery (LVR) after acute ST-elevation myocardial infarction (STEMI) is challenging and of prognostic importance. Our objective was to evaluate the usefulness of noninvasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LVR and in-hospital complications after STEMI.
Methods
Ninety-three patients with anterior STEMI (mean age, 59 ± 12 years) treated by percutaneous coronary intervention (PCI) were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24-48 hours after PCI and a median of 92 days at follow-up. Myocardial work is derived from the strain-pressure relation, integrating in its calculation the noninvasive arterial pressure. Segmental LVR was defined as a normalization of wall motion abnormalities of the affected segments and global recovery as an absolute improvement of left ventricular ejection fraction (LVEF) > 5% in patients with baseline LVEF ≤ 50%. In-hospital complications were defined as a composite of death, reinfarction, heart failure, and LV apical thrombus.
Results
Segmental MW was impaired in infarct segments, more severely in nonrecovering versus recovering segments (P < .01). Furthermore, global constructive MW was significantly correlated with follow-up LVEF (r = 0.58) and global longitudinal strain (r = -0.67; all P < .01). Constructive MW was the best index to predict segmental (P < .01 vs MW index, MW efficiency, and wasted work) and global recovery (P < .05 vs global longitudinal strain) with an independent association (odds ratio = 1.17, 95% CI, 1.13-1.20, and odds ratio = 1.43, 95% CI, 1.18-1.68, respectively; all P < .001). Moreover, global constructive MW was more severely impaired in patients with in-hospital complications (n = 16; P < .01).
Conclusions
In patients with anterior STEMI treated by PCI, constructive MW is an independent predictor of segmental and global LVR and is significantly impaired in patients with in-hospital complications.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1180-1190
Meimoun P, Abdani S, Stracchi V, Elmkies F, ... Zemir H, Clerc J
J Am Soc Echocardiogr: 29 Sep 2020; 33:1180-1190 | PMID: 33010853
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Impact:
Abstract

Outcomes and predictors of cardiac events in medically treated patients with atrial functional mitral regurgitation.

Kim K, Kitai T, Kaji S, Pak M, ... Kinoshita M, Furukawa Y
Background
Little is known about the outcomes and predictors of adverse cardiac events in medically treated patients with atrial functional mitral regurgitation (FMR).
Methods
We screened 1405 consecutive patients with grade ≥ 3+ mitral regurgitation (MR) detected by echocardiography. After excluding patients with previous or early (within 3 months from diagnosis) mitral valve surgery, congenital heart disease, hypertrophic cardiomyopathy, severe aortic valve disease, or unknown etiology, the study population consisted of 319 patients with primary MR, 395 patients with FMR with left ventricular (LV) dysfunction, and 184 patients with atrial FMR. Atrial FMR was defined as FMR in patients without LV wall motion abnormality or dilatation.
Results
The cumulative incidence of the composite of cardiac death and heart failure hospitalization at 3 years was 10.5% in primary MR, 37.5% in FMR with LV dysfunction, and 14.0% in atrial FMR (p < .001). In atrial FMR patients, LV end-diastolic volume index (hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.02-1.10), severe MR (grade 4+) (HR 2.73, 95% CI 1.21-6.12), being symptomatic (NYHA ≥ 2) (HR 2.82, 95% CI 1.15-6.92), and having ≥1 comorbidities (HR 3.96, 95% CI 1.74-9.00) were independently associated with an increased risk for adverse cardiac events by a multivariable Cox regression analysis.
Conclusions
Outcomes of medically treated patients with atrial FMR were better than those of FMR with LV dysfunction, but worse than those of primary MR. In atrial FMR patients, LV dilatation, severe MR, being symptomatic, and the presence of comorbidities were independently associated with an increased risk for adverse cardiac events.

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

Int J Cardiol: 30 Sep 2020; 316:195-202
Kim K, Kitai T, Kaji S, Pak M, ... Kinoshita M, Furukawa Y
Int J Cardiol: 30 Sep 2020; 316:195-202 | PMID: 32610155
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Impact:
Abstract

Automated extraction of left atrial volumes from two-dimensional computer tomography images using a deep learning technique.

Chen HH, Liu CM, Chang SL, Chang PY, ... Chen SA, Lu HH
Background
Precise segmentation of the left atrium (LA) in computed tomography (CT) images constitutes a crucial preparatory step for catheter ablation in atrial fibrillation (AF). We aim to apply deep convolutional neural networks (DCNNs) to automate the LA detection/segmentation procedure and create three-dimensional (3D) geometries.
Methods
Five hundred eighteen patients who underwent procedures for circumferential isolation of four pulmonary veins were enrolled. Cardiac CT images (from 97 patients) were used to construct the LA detection and segmentation models. These images were reviewed by the cardiologists such that images containing the LA were identified/segmented as the ground truth for model training. Two DCNNs which incorporated transfer learning with the architectures of ResNet50/U-Net were trained for image-based LA classification/segmentation. The LA geometry created by the deep learning model was correlated to the outcomes of AF ablation.
Results
The LA detection model achieved an overall 99.0% prediction accuracy, as well as a sensitivity of 99.3% and a specificity of 98.7%. Moreover, the LA segmentation model achieved an intersection over union of 91.42%. The estimated mean LA volume of all the 518 patients studied herein with the deep learning model was 123.3 ± 40.4 ml. The greatest area under the curve with a LA volume of 139 ml yielded a positive predictive value of 85.5% without detectable AF episodes over a period of one year following ablation.
Conclusions
The deep learning provides an efficient and accurate way for automatic contouring and LA volume calculation based on the construction of the 3D LA geometry.

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

Int J Cardiol: 30 Sep 2020; 316:272-278
Chen HH, Liu CM, Chang SL, Chang PY, ... Chen SA, Lu HH
Int J Cardiol: 30 Sep 2020; 316:272-278 | PMID: 32507394
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Impact:
Abstract

Prevalence of left ventricular hypertrabeculation/noncompaction among patients with congenital dyserythropoietic anemia Type 1 (CDA1).

Abramovich-Yoffe H, Shalev A, Barrett O, Shalev H, Levitas A
Background
Congenital dyserythropoietic anemia type 1 (CDA1) is a rare autosomal recessive disease characterized by macrocytic anemia, ineffective erythropoiesis, and secondary hemochromatosis. Left-ventricular noncompaction (LVNC) is a cardiomyopathy that is commonly attributed to intrauterine arrest of normal compaction during the endomyocardial morphogenesis. LV hypertrabeculation/noncompaction (LVHT/NC) morphology, however, might exist in various hemoglobinopathies. Our primary objective was to determine whether the pattern of LVHT/NC is more prevalent among patients with CDA1, in comparison to subjects without CDA1, and to find potential risk factors for LVHT/NC among these patients. Our secondary objective was to evaluate the clinical implication of LVHT/NC.
Methods
We retrospectively assessed 32 CDA1 patients (median age 17.5, range 6-61) that underwent routine assessment of iron overload by cardiac magnetic resonance. Number and distribution of noncompacted LV segments were assessed in CDA1 patients and compared to 64 age- and gender-matched patients without CDA1. The ratio of noncompacted to compacted myocardium (NC/C ratio) in end-diastole was calculated for each of the three long-axis views. NC/C ratio > 2.3 was considered diagnostic for LVHT/NC.
Results
In multivariate analysis, the presence of CDA1 was independently associated with NC/C ratio > 2.3, a feature of LVHT/NC (adjusted OR = 11.46, 95%CI = 2.6-50.68, p = .001). CDA1 was strongly associated with increased number of myocardial segments exhibiting LVHT/NC pattern. Cardiac volumes and ejection fraction were preserved without clinical adverse events in long term follow-up.
Conclusions
CDA1 patients have a higher prevalence of LVHT/NC than normal individuals, independent of myocardial iron overload and without effect on ejection fraction or clinical outcome.

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

Int J Cardiol: 14 Oct 2020; 317:96-102
Abramovich-Yoffe H, Shalev A, Barrett O, Shalev H, Levitas A
Int J Cardiol: 14 Oct 2020; 317:96-102 | PMID: 32512057
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Impact:
Abstract

Are left atrial diverticula and left-sided septal pouches relevant additional findings in cardiac CT? Correlation between left atrial outpouching structures and ischemic brain alterations.

Celik E, Pennig L, Laukamp KR, Hammes J, ... Caldeira L, Hickethier T
Purpose
To evaluate the correlation between left atrial diverticula (LAD) and left-sided septal pouches (LSSP) with ischemic brain alterations in MRI.
Methods
A retrospective analysis of 174 patients who received both, a dedicated cardiac CT angiography (CCTA) and a brain MRI examination was performed. Two radiologists independently reviewed all examinations for the presence of LAD and LSSP as well as ischemic alterations of the brain. Subsequently, the correlation between these cardiac and cerebral findings as well as to other potentially related risk factors was assessed.
Results
71 LAD (total prevalence 41%) and 65 LSSP (total prevalence 37%) were identified in 174 patients. Combined prevalence was 10%. Ischemic brain alterations were found in patients with a LAD in 42.3% (30/71) and with a LSSP in 64.6% (42/65). Patients without any anatomical variant in the left atrium showed ischemic brain alterations in 39.4% (26/66). The presence of a LSSP was associated with an increased risk for ischemic brain alterations in multivariate logistic regression analysis after adjusting for other risk factors (OR = 3.57, 95% CI = 0.51-2.09, p <  .01).
Conclusion
In our study cohort LAD and LSSP are highly prevalent anatomical structures within the left atrium. Patients with LSSP showed an approximated 3.5-fold higher probability for ischemic brain alterations. Therefore, LSSP should be considered as a potential risk factor for cardioembolic strokes and its presence should be stated in cardiac CT reports.

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

Int J Cardiol: 14 Oct 2020; 317:216-220
Celik E, Pennig L, Laukamp KR, Hammes J, ... Caldeira L, Hickethier T
Int J Cardiol: 14 Oct 2020; 317:216-220 | PMID: 32461119
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Impact:
Abstract

State-of-the-art preclinical testing of the OMEGA left atrial appendage occluder.

De Backer O, Hafiz H, Fabre A, Lertsapcharoen P, ... Foley D, Sondergaard L
Objectives
This study aimed to present a new approach of thorough preclinical testing of a novel left atrial appendage (LAA) occluder device.
Background
The development of a safe and effective LAA occluder has been shown to be challenging.
Methods
The novel OMEGATM LAA occluder (Eclipse Medical, Ireland) was tested in a porcine model and three-dimensional (3D) human LAA models - this as a prelude to its first-in-human use.
Results
In a first series of in-vivo experiments, the OMEGATM LAA occluder was shown to have a satisfactory device biocompatibility in a porcine model. The design of the OMEGATM device was further refined and optimized following three more series of in-vivo experiments. The second generation OMEGATM device was designed with thinner wires, leading to a profile reduction. Based on in-vitro testing of different OMEGATM device sizes implanted at different depths in human three-dimensional (3D) LAA models, it could be determined that (1) the landing zone should be measured at a median depth of 12 mm from the LAA ostium; (2) the distal self-retaining inverted cup should have 10%-25% compression to minimize device embolization risk; and (3) the disc should be slightly inverted, i.e. pulled into the LAA, to promote complete LAA occlusion. The combined in-vivo and in-vitro testing resulted in an optimized pre-procedural planning of the first-in-human case treated with the OMEGATM device.
Conclusions
This series of carefully planned in-vivo and in-vitro experiments allowed demonstration of the safety and efficacy of the OMEGATM LAA occluder. This approach of thorough preclinical testing of medical devices may reduce the risk of complications in first-in-human cases and may become the standard approach for device development and preclinical testing in the future.

© 2020 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 08 Oct 2020; epub ahead of print
De Backer O, Hafiz H, Fabre A, Lertsapcharoen P, ... Foley D, Sondergaard L
Catheter Cardiovasc Interv: 08 Oct 2020; epub ahead of print | PMID: 33034944
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Impact:
Abstract

Color Doppler Splay: A Clue to the Presence of Significant Mitral Regurgitation.

Wiener PC, Friend EJ, Bhargav R, Radhakrishnan K, Kadem L, Pressman GS
Background
The authors describe a previously unreported Doppler signal associated with mitral regurgitation (MR) as imaged using transthoracic echocardiography. Horizontal \"splay\" of the color Doppler signal along the atrial surface of the valve may indicate significant regurgitation when the MR jet otherwise appears benign.
Methods
Splay was defined as a nonphysiologic arc of color centered at the point at which the MR jet emerges into the left atrium. The authors present a series of 10 cases of clinically significant MR (moderately severe or severe as defined by transesophageal echocardiography) that were misclassified on transthoracic echocardiography as less than moderate. The splay signal was present on at least one standard transthoracic view in each case. To better characterize the splay signal, two groups were created from existing clinically driven transthoracic echocardiograms: 100 consecutive patients with severe MR and 100 with mild MR.
Results
Splay was present in the majority of severe MR cases (81%) regardless of vendor machine, ejection fraction, or MR etiology. Splay was particularly prevalent among patients with wall-hugging jets (28 of 30 [93%]). In patients with mild MR, splay was present less often (16%), on fewer frames per clip, and had smaller dimensions compared with severe MR. Color scale did not differ between subjects with and those without splay, but color gain was higher when splay was present (P = .04). Machine settings were further explored in a single subject with prominent splay: increasing transducer frequency reduced splay, while increasing color gain increased it.
Conclusions
The authors describe a new transthoracic echocardiographic sign of MR. Horizontal splay may be a clue to the presence of severe MR when the main body of the jet is out of the imaging plane. Splay is likely generated as a side-lobe artifact due to a high-flux regurgitant jet.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1212-1219.e1
Wiener PC, Friend EJ, Bhargav R, Radhakrishnan K, Kadem L, Pressman GS
J Am Soc Echocardiogr: 29 Sep 2020; 33:1212-1219.e1 | PMID: 32712051
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Impact:
Abstract

Effect of Short-Term L-Thyroxine Therapy on Left Ventricular Mechanics in Idiopathic Dilated Cardiomyopathy.

Badran HM, Faheem N, Zidan A, Yacoub MH, Soltan G
Objective
Previous experimental studies have provided evidence of notable changes in thyroid hormone signaling that corresponds to alterations in myocardial function in animal models of heart failure (HF). The present study further explores whether oral thyroid hormone treatment can change left ventricular (LV) mechanics and functional status in patients with idiopathic dilated cardiomyopathy (IDCM) or not.
Methods
Sixty IDCM patients who were receiving conventional HF treatment were randomized to oral L-thyroxine (n = 40) or placebo (n = 20) for 3 months. Fifty-two (86.7%) of all IDCM patients were symptomatic, their mean age was 41 ± 12 years, and their ejection fraction was 32% ± 7%. At baseline, the two groups were comparable in clinical and echocardiographic variables. Vector velocity imaging was utilized to assess LV mechanics. Myocardial longitudinal peak systolic strain, systolic strain rate, early and late diastolic strain rate, circumferential strain, LV dyssynchrony, plasma tri-iodothyronine, thyroxine, and thyroid stimulating hormone levels were measured at baseline and 3 months after treatment.
Results
All patients receiving L-thyroxine significantly improved in functional status (New York Heart Association class; P < .001) and echocardiographic parameters including end-diastolic diameter (P < .001), end-systolic diameter (P < .001), mitral regurgitation severity reduction (P < .001), and increased ejection fraction (P < .001). Left ventricular mechanics showed marked improvement at segmental and global levels of both longitudinal and circumferential myocardial strain (P < .005) when compared with placebo group.
Conclusions
Short-term L-thyroxine therapy is well tolerated in IDCM patients. It improves cardiac mechanics and functional status, which might support the potential role of synthetic thyroid hormones in HF treatment.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1234-1244
Badran HM, Faheem N, Zidan A, Yacoub MH, Soltan G
J Am Soc Echocardiogr: 29 Sep 2020; 33:1234-1244 | PMID: 32792320
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Impact:
Abstract

Utility of Three-Dimensional Transesophageal Echocardiography for Mitral Annular Sizing in Transcatheter Mitral Valve Replacement Procedures: A Cardiac Computed Tomographic Comparative Study.

Coisne A, Pontana F, Aghezzaf S, Mouton S, ... Modine T, Montaigne D
Background
Three-dimensional (3D) transesophageal echocardiographic (TEE) imaging is frequently used as an initial screening tool in the evaluation of patients who are candidates for transcatheter mitral valve replacement (TMVR). However, little is known about the imaging correlation with the gold standard, computed tomographic (CT) imaging. The aims of this study were to test the quantitative differences between these two modalities and to determine the best 3D TEE parameters for TMVR screening.
Methods
Fifty-seven patients referred to the heart valve clinic for TMVR with prostheses specifically designed for the mitral valve were included. Mitral annular (MA) analyses were performed using commercially available software on 3D TEE and CT imaging.
Results
Three-dimensional TEE imaging was feasible in 52 patients (91%). Although 3D TEE measurements were slightly lower than those obtained on CT imaging, measurements of both projected MA area and perimeter showed excellent correlations, with small differences between the two modalities (r = 0.88 and r = 0.92, respectively, P < .0001). Correlations were significant but lower for MA diameters (r = 0.68-0.72, P < .0001) and mitroaortic angle (r = 0.53, P = .0001). Receiver operating characteristic curve analyses showed that 3D TEE imaging had a good ability to predict TMVR screening success, defined by constructors on the basis of CT measurements, with ranges of 12.9 to 15 cm for MA area (area under the curve [AUC] = 0.88-0.91, P < .0001), 128 to 139 mm for MA perimeter (AUC = 0.85-0.91, P < .0001), 35 to 39 mm for anteroposterior diameter (AUC = 0.79-0.84, P < .0001), and 37 to 42 mm for posteromedial-anterolateral diameter (AUC = 0.81-0.89, P < .0001).
Conclusions
Three-dimensional TEE measurements of MA dimensions display strong correlations with CT measurements in patients undergoing TMVR screening. Three-dimensional TEE imaging should be proposed as a reasonable alternative to CT imaging in this vulnerable population.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1245-1252.e2
Coisne A, Pontana F, Aghezzaf S, Mouton S, ... Modine T, Montaigne D
J Am Soc Echocardiogr: 29 Sep 2020; 33:1245-1252.e2 | PMID: 32718722
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Impact:
Abstract

Noninvasive Myocardial Work Indices 3 Months after ST-Segment Elevation Myocardial Infarction: Prevalence and Characteristics of Patients with Postinfarction Cardiac Remodeling.

Lustosa RP, van der Bijl P, El Mahdiui M, Montero-Cabezas JM, ... Bax JJ, Delgado V
Background
Assessment of left ventricular (LV) remodeling after ST-segment elevation myocardial infarction (STEMI) is pivotal for patient management. Noninvasive myocardial work indices obtained from echocardiography-derived strain-pressure loops provide a new tool that permits characterization of LV mechanics. We aimed at characterizing myocardial work indices in patients with LV remodeling after STEMI versus patients without remodeling.
Methods
Six-hundred STEMI patients were retrospectively analyzed (456 men, mean age: 61 ± 11 years) and divided according to the presence of LV remodeling 3 months after the index admission (≥20% increase in LV end-diastolic volume). Noninvasive myocardial work indices were measured at 3 months after STEMI.
Results
LV remodeling was observed in 150 patients (25%) who showed more impaired global myocardial work indices compared with their counterparts: work index (1,708 ± 522 mm Hg% vs 1,979 ± 450 mm Hg%; P < .001), constructive work (1,941 ± 598 mm Hg% vs 2,272 ± 519 mm Hg%; P < .001), and work efficiency (92% [range 88%-96%] vs 95% [range 93%-96%]; P < .001). In addition, patients with LV remodeling had significantly increased wasted work (116 mm Hg% [range 73-184 mm Hg%] vs 91 mm Hg% [range 61-132 mm Hg%]; P < .001). The frequency of impaired global work index, constructive and work efficiency, and increased wasted work was significantly higher among patients with LV remodeling compared with their counterparts: 21.3%, 34.7%, 34.7%, and 14.0%, respectively, versus 5.3%, 9.6%, 8.9%, and 4.9%, respectively (P < .001).
Conclusions
At 3-month follow-up after STEMI, patients with LV remodeling revealed more impaired myocardial work indices compared with patients without LV remodeling. The prevalence of impaired myocardial work indices was higher among patients with LV remodeling compared with patients without.

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

J Am Soc Echocardiogr: 29 Sep 2020; 33:1172-1179
Lustosa RP, van der Bijl P, El Mahdiui M, Montero-Cabezas JM, ... Bax JJ, Delgado V
J Am Soc Echocardiogr: 29 Sep 2020; 33:1172-1179 | PMID: 32651125
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Impact:
Abstract

Cardiac Reserve and Exercise Capacity: Insights from Combined Cardiopulmonary and Exercise Echocardiography Stress Testing.

Pugliese NR, De Biase N, Conte L, Gargani L, ... Borlaug BA, Masi S
Background
Cardiopulmonary exercise testing (CPET) represents the gold standard to estimate peak oxygen consumption (VO) noninvasively. To improve the analysis of the mechanisms behind effort intolerance, we examined whether exercise stress echocardiography measurements relate to directly measured peak VO during exercise in a large cohort of patients within the heart failure (HF) spectrum.
Methods
We performed a symptom-limited graded ramp bicycle CPET exercise stress echocardiography in 30 healthy controls and 357 patients: 113 at risk of developing HF (American College of Cardiology/American Heart Association stage A-B) and 244 in HF stage C with preserved (HFpEF, n = 101) or reduced ejection fraction (HFrEF, n = 143).
Results
Peak VO significantly decreased from controls (23, 21.7-29.7 mL/kg/minute; median, interquartile range) to stage A-B (18, 15.4-20.7 mL/kg/minute) and stage C (HFpEF: 13.6, 11.8-16.8 mL/kg/minute; HFrEF: 14.2, 10.7-17.5 mL/kg/minute). A regression model to predict peak VO revealed that peak left ventricular (LV) systolic annulus tissue velocity (S\'), peak tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (right ventricle-pulmonary artery coupling), and low-load left atrial (LA) reservoir strain/E/e\' (LA compliance) were independent predictors, in addition to peak heart rate, stroke volume, and workload (adjusted R = 0.76, P < .0001). The model was successfully tested in subjects with atrial fibrillation (n = 49) and with (n = 224) and without (n = 163) beta-blockers (all P < .01). Peak S\' showed the highest accuracy in predicting peak VO < 10 mL/kg/minute (cut point ≤ 7.5 cm/sec, area under the curve = 0.92, P < .0001) and peak VO > 20 mL/kg/minute (cut point > 12.5 cm/sec, area under the curve = 0.84, P < .0001) in comparison with the other cardiac variables of the model (P < .05).
Conclusions
Peak VO is directly related to measures of LV systolic function, LA compliance, and right ventricle-pulmonary artery coupling, in addition to heart rate and stroke volume and independently of workload, age, and sex. The evaluation of cardiac mechanics may provide more insights into the causes of effort intolerance in subjects from HF stages A-C.

Copyright © 2020 American Society of Echocardiography. All rights reserved.

J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print
Pugliese NR, De Biase N, Conte L, Gargani L, ... Borlaug BA, Masi S
J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print | PMID: 33036818
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Impact:
Abstract

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

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

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

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

Cardiac fibroblast activation detected by Ga-68 FAPI PET imaging as a potential novel biomarker of cardiac injury/remodeling.

Siebermair J, Köhler MI, Kupusovic J, Nekolla SG, ... Rassaf T, Rischpler C
Background
Fibroblast activation protein (FAP) as a specific marker of activated fibroblasts can be visualized by positron emission tomography (PET) using Ga-68-FAP inhibitors (FAPI). Gallium-68-labeled FAPI is increasingly used in the staging of various cancers. In addition, the first cases of theranostic approaches have been reported. In this work, we describe the phenomenon of myocardial FAPI uptake in patients who received a Ga-68 FAPI PET for tumor staging.
Method and results
Ga-68 FAPI PET examinations for cancer staging were retrospectively analyzed with respect to cardiac tracer uptake. Standardized uptake values (SUV) were correlated to clinical covariates in a univariate regression model. From 09/2018 to 11/2019 N = 32 patients underwent FAPI PET at our institution. Six out of 32 patients (18.8%) demonstrated increased localized myocardial tracer accumulation, with remote FAPI uptake being significantly higher in patients with vs without localized focal myocardial uptake (SUV 2.2 ± .6 vs 1.5 ± .4, P < .05 and SUV 1.6 ± .4 vs 1.2 ± .3, P < .05, respectively). Univariate regression demonstrated a significant correlation of coronary artery disease (CAD), age and left ventricular ejection fraction (LVEF) with remote SUV uptake, the latter with a very strong correlation with remote uptake (R = .74, P < .01).
Conclusion
Our study indicates an association of CAD, age, and LVEF with FAPI uptake. Further studies are warranted to assess if fibroblast activation can be reliably measured and may be used for risk stratification regarding early detection or progression of CAD and left ventricular remodeling.



J Nucl Cardiol: 24 Sep 2020; epub ahead of print
Siebermair J, Köhler MI, Kupusovic J, Nekolla SG, ... Rassaf T, Rischpler C
J Nucl Cardiol: 24 Sep 2020; epub ahead of print | PMID: 32975729
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Impact:
Abstract

Diagnostic utility of fusion F-fluorodeoxyglucose positron emission tomography/cardiac magnetic resonance imaging in cardiac sarcoidosis.

Okune M, Yasuda M, Soejima N, Kagioka Y, ... Miyazaki S, Iwanaga Y
Background
Although each F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) has been used to diagnose cardiac sarcoidosis (CS), active CS is still misdiagnosed.
Methods
Active CS, diagnosed by PET alone, was defined as focal or focal on diffuse FDG uptake pattern. In fusion PET/CMR imaging, using a regional analysis with AHA 17-segment model, the patients were categorized into four groups: (1) PET-/LGE-, (2) PET+/LGE-, (3) PET+/LGE+, and (4) PET-/LGE+. PET+/LGE+ was defined as active CS.
Results
74 Patients with suspected CS were enrolled. Between PET alone and fusion PET/CMR imaging, 20 cases had mismatch evaluations of active CS, and most had diffuse or focal on diffuse FDG uptake pattern on PET alone imaging. 40 Patients fulfilled the 2016 the Japanese Circulation Society diagnostic criteria for CS. The interobserver diagnostic agreement was excellent (κ statistics 0.89) and the overall accuracy for diagnosing CS was 87.8% in fusion PET/CMR imaging, which were superior to those in PET alone imaging (0.57 and 82.4%, respectively). In a sub-analysis of diffuse and focal on diffuse patterns, the agreement (κ statistics 0.86) and overall accuracy (81.8%) in fusion PET/CMR imaging were still better.
Conclusions
Fusion PET/CMR imaging with regional analysis offered reliable and accurate diagnosis of CS, covering low diagnostic area by FDG-PET alone.



J Nucl Cardiol: 30 Sep 2020; epub ahead of print
Okune M, Yasuda M, Soejima N, Kagioka Y, ... Miyazaki S, Iwanaga Y
J Nucl Cardiol: 30 Sep 2020; epub ahead of print | PMID: 33000410
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Impact:
Abstract

18F-fluoride PET/MR in cardiac amyloid: A comparison study with aortic stenosis and age- and sex-matched controls.

Andrews JPM, Trivieri MG, Everett R, Spath N, ... Fayad ZA, Dweck MR
Objectives
Cardiac MR is widely used to diagnose cardiac amyloid, but cannot differentiate AL and ATTR subtypes: an important distinction given their differing treatments and prognoses. We used PET/MR imaging to quantify myocardial uptake of 18F-fluoride in ATTR and AL amyloid patients, as well as participants with aortic stenosis and age/sex-matched controls.
Methods
In this prospective multicenter study, patients were recruited in Edinburgh and New York and underwent 18F-fluoride PET/MR imaging. Standardized volumes of interest were drawn in the septum and areas of late gadolinium enhancement to derive myocardial standardized uptake values (SUV) and tissue-to-background ratio (TBR) after correction for blood pool activity in the right atrium.
Results
53 patients were scanned: 18 with cardiac amyloid (10 ATTR and 8 AL), 13 controls, and 22 with aortic stenosis. No differences in myocardial TBR values were observed between participants scanned in Edinburgh and New York. Mean myocardial TBR values in ATTR amyloid (1.13 ± 0.16) were higher than controls (0.84 ± 0.11, P = .0006), aortic stenosis (0.73 ± 0.12, P < .0001), and those with AL amyloid (0.96 ± 0.08, P = .01). TBR values within areas of late gadolinium enhancement provided discrimination between patients with ATTR (1.36 ± 0.23) and all other groups (e.g., AL [1.06 ± 0.07, P = .003]). A TBR threshold >1.14 in areas of LGE demonstrated 100% sensitivity (CI 72.25 to 100%) and 100% specificity (CI 67.56 to 100%) for ATTR compared to AL amyloid (AUC 1, P = .0004).
Conclusion
Quantitative 18F-fluoride PET/MR imaging can distinguish ATTR amyloid from other similar phenotypes and holds promise in improving the diagnosis of this condition.



J Nucl Cardiol: 29 Sep 2020; epub ahead of print
Andrews JPM, Trivieri MG, Everett R, Spath N, ... Fayad ZA, Dweck MR
J Nucl Cardiol: 29 Sep 2020; epub ahead of print | PMID: 33000405
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Impact:
Abstract

Prognostic value of myocardial perfusion imaging with D-SPECT camera in patients with ischemia and no obstructive coronary artery disease (INOCA).

Liu L, Abdu FA, Yin G, Xu B, ... Xu Y, Che W
Background
Myocardial perfusion imaging (MPI) with a novel D-SPECT camera maintains excellent prognostic value compared to conventional SPECT. However, information about the relationship between D-SPECT MPI and the prognosis in patients with ischemia and no obstructive coronary artery disease (INOCA) is limited. The objective of this study was to evaluate the prognostic value of MPI with D-SPECT in INOCA and obstructive coronary artery disease (CAD) patients.
Methods
All consecutive patients with suspected CAD and without prior CAD who underwent D-SPECT MPI and invasive coronary angiography within 3 months were considered. INOCA and obstructive CAD were defined as < 50% and ≥ 50% coronary stenosis, respectively. Patients were followed-up for the occurrence of major adverse cardiac events (MACE: cardiovascular death, nonfatal myocardial infarction, revascularization, stroke, heart failure and angina-related rehospitalization).
Results
Among 506 patients, 232 (45.8%) were INOCA patients. A total of 33.2% of the INOCA patients had abnormal D-SPECT MPI, whereas 77.7% of the obstructive CAD patients had abnormal D-SPECT MPI. In both groups, patients with abnormal D-SPECT MPI demonstrated higher MACE rates and lower survival free of MACE. In addition, patients with INOCA and abnormal D-SPECT MPI had a poor prognosis similar to that of the obstructive CAD patients. Cox regression analysis showed that the risk-adjusted hazard ratios for abnormal D-SPECT MPI were 2.55 [1.11-5.87] and 2.06 [1.03-4.10] in the INOCA and obstructive CAD patients, respectively.
Conclusions
D-SPECT MPI provides excellent prognostic information, with a more severe prognosis in patients with abnormal D-SPECT MPI. INOCA patients with abnormal D-SPECT MPI experience a poor prognosis similar to that of patients with obstructive CAD.



J Nucl Cardiol: 29 Sep 2020; epub ahead of print
Liu L, Abdu FA, Yin G, Xu B, ... Xu Y, Che W
J Nucl Cardiol: 29 Sep 2020; epub ahead of print | PMID: 33000403
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Impact:
Abstract

The indications and utility of adjunctive imaging modalities for chronic total occlusion (CTO) intervention.

Allahwala UK, Brilakis ES, Kiat H, Ayesa S, ... Weaver JC, Bhindi R

Coronary chronic total occlusions (CTO) are common in patients undergoing coronary angiography, yet the optimal management strategy remains uncertain, with conflicting results from randomized trials. Appropriate patient selection and careful periprocedural planning are imperative for successful patient management. We review the role of adjunctive imaging modalities including myocardial perfusion imaging (MPI), cardiac magnetic resonance imaging (CMR), echocardiography and computed tomography coronary angiography (CTCA) in myocardial ischemic quantification, myocardial viability assessment, as well as procedural planning for CTO revascularization. An appreciation of the value, indications and limitations of these modalities prior to planned intervention are essential for optimal management.



J Nucl Cardiol: 05 Oct 2020; epub ahead of print
Allahwala UK, Brilakis ES, Kiat H, Ayesa S, ... Weaver JC, Bhindi R
J Nucl Cardiol: 05 Oct 2020; epub ahead of print | PMID: 33025478
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Impact:
Abstract

Diagnostic performance of prone-only myocardial perfusion imaging versus coronary angiography in the detection of coronary artery disease: A systematic review and meta-analysis.

Mirshahvalad SA, Chavoshi M, Hekmat S
Study design
Although prone position is considered as a complementary protocol in myocardial perfusion imaging (MPI), there is no consensus on its capability to find coronary artery disease (CAD), independently. The primary aim of this review was to report pooled sensitivity and specificity for prone position MPI in detection of CAD. In addition, the results were compared to the supine position\'s performance.
Methods
Electronic bibliographic databases, The Cochrane Library, Web of Science (Science and Social Science Citation Index), Scopus, PubMed, and EMBASE until the end of June 2020 were searched. Studies were included based on the inclusion criteria of (1) evaluated the prone position MPI, (2) defined CAD with coronary angiography (CAG), using the threshold of ≥ 50% stenosis, (3) Adequate data were provided to extract the diagnostic performance. QUADAS-2 tool was utilized to assess the quality of included studies. Pooled sensitivity and specificity were calculated for prone and supine positions, separately. The hierarchical summary ROC curves were also drawn.
Results
Ten individual studies with the data of the 1490 patients for the prone position and 1138 patients for the supine position were included. Pooled sensitivity and specificity for the prone position were 83% and 79%, respectively. These results were calculated for the supine position as the sensitivity of 86% and specificity of 67%. The pooled sensitivity and specificity of the prone position in detecting the right coronary artery territory defects were 70% and 84%, in turn.
Conclusion
In the suspicion for the CAD, prone position with comparable sensitivity and higher specificity can be an acceptable alternative to the supine position as the standard method. Also, in the cases of possible defects in the RCA territory, prone position showed to be a superior standard.



J Nucl Cardiol: 05 Oct 2020; epub ahead of print
Mirshahvalad SA, Chavoshi M, Hekmat S
J Nucl Cardiol: 05 Oct 2020; epub ahead of print | PMID: 33025477
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Impact:
Abstract

Psychological factors of suspect coronary microvascular dysfunction in patients undergoing SPECT imaging.

Bekendam MT, Vermeltfoort IAC, Kop WJ, Widdershoven JW, Mommersteeg PMC
Background
Patients with myocardial ischemia in the absence of obstructive coronary artery disease (CAD) often experience anginal complaints and are at risk of cardiac events. Stress-related psychological factors and acute negative emotions might play a role in these patients with suspect coronary microvascular dysfunction (CMD).
Methods and results
295 Patients (66.9 ± 8.7 years, 46% women) undergoing myocardial perfusion single-photon-emission computed tomography (MPI-SPECT), were divided as follows: (1) a non-ischemic reference group (n = 136); (2) patients without inducible ischemia, but with a history of CAD (n = 62); (3) ischemia and documented CAD (n = 52); and (4) ischemia and suspect CMD (n = 45). These four groups were compared with regard to psychological factors and acute emotions. Results revealed no differences between the groups in psychological factors (all P > .646, all effect sizes d < .015). State sadness was higher for patients with suspect CMD (16%) versus the other groups (P = .029). The groups did not differ in the association of psychological factors or emotions with anginal complaints (all P values > .448).
Conclusion
Suspect CMD was not associated with more negative psychological factors compared to other groups. State sadness was significantly higher for patients with suspect CMD, whereas no differences in state anxiety and other psychological factors were found.



J Nucl Cardiol: 05 Oct 2020; epub ahead of print
Bekendam MT, Vermeltfoort IAC, Kop WJ, Widdershoven JW, Mommersteeg PMC
J Nucl Cardiol: 05 Oct 2020; epub ahead of print | PMID: 33025473
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Impact:
Abstract

F-flutemetamol positron emission tomography in cardiac amyloidosis.

Papathanasiou M, Kessler L, Carpinteiro A, Hagenacker T, ... Luedike P, Rischpler C
Purpose
Bone-tracer scintigraphy has an established role in diagnosis of cardiac amyloidosis (CA) as it detects transthyretin amyloidosis (ATTR). Positron emission tomography (PET) with amyloid tracers has shown high sensitivity for detection of both ATTR and light-chain (AL) CA. We aimed to investigate the accuracy of F-flutemetamol in CA.
Methods
We enrolled patients with CA or non-amyloid heart failure (NA-HF), who underwent cardiac F-flutemetamol PET/MRI or PET/CT. Myocardial and blood pool standardized tracer uptake values (SUV) were estimated. Late gadolinium enhancement (LGE) and T1 mapping/ extracellular volume (ECV) estimation were performed.
Results
We included 17 patients (12 with CA, 5 with NA-HF). PET/MRI was conducted in 13 patients, while PET/CT was conducted in 4. LGE was detected in 8 of 9 CA patients. Global relaxation time and ECV were higher in CA (1448 vs. 1326, P = 0.02 and 58.9 vs. 33.7%, P = 0.006, respectively). Positive PET studies were demonstrated in 2 of 12 patients with CA (AL and ATTR). Maximal and mean SUV did not differ between groups (2.21 vs. 1.69, P = 0.18 and 1.73 vs. 1.30, P = 0.13).
Conclusion
Although protein-independent binding is supported by our results, the diagnostic yield of PET was low. We demonstrate here for the first time the low sensitivity of PET for CA.



J Nucl Cardiol: 05 Oct 2020; epub ahead of print
Papathanasiou M, Kessler L, Carpinteiro A, Hagenacker T, ... Luedike P, Rischpler C
J Nucl Cardiol: 05 Oct 2020; epub ahead of print | PMID: 33025472
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Impact:
Abstract

The diagnostic and prognostic value of near-normal perfusion or borderline ischemia on stress myocardial perfusion imaging.

Kassab K, Hussain K, Torres A, Iskander F, ... Khan R, Doukky R
Background
Data on the diagnostic and prognostic value of subtle abnormalities on myocardial perfusion imaging (MPI) are limited.
Methods and results
In a retrospective single-center cohort of patients who underwent regadenoson SPECT-MPI, near-normal MPI was defined as normal left ventricular ejection fraction (LVEF ≥ 50%) and a summed stress score (SSS) of 1-3 vs SSS = 0 in normal MPI. Borderline ischemia was defined as normal LVEF, SSS = 1-3, and a summed difference score (SDS) of 1 vs SDS = 0 in the absence of ischemia. Coronary angiography data within 6 months from MPI were tabulated. Patients were followed for cardiac death (CD), myocardial infarction (MI), coronary revascularization (CR), and Late CR (LCR) [> 90 days post MPI]. Among 6,802 patients (mean age, 62 ± 13 years; 42% men), followed for a mean of 2.5 ± 2.1 years, 4,398 had normal MPI, 2,404 had near-normal MPI, and 972 had borderline ischemia. Among patients who underwent angiography within 6 months, obstructive (≥ 70% or left main ≥ 50%) CAD was observed at higher rates among subjects with near-normal MPI (33.5% vs 25.5%; P = .049) and those with borderline ischemia (40.5% vs 25.8%; P = .004). During follow-up, 158 (2.3%) CD/MI, 246 (3.6%) CR, and 150 (2.2%) LCR were observed. Near-normal MPI (SSS = 1-3), compared to normal MPI (SSS = 0), was not associated with a significant difference in the risk of the composite endpoint of CD/MI (Hazard ratio [HR], 1.21; 95% confidence interval [CI], .88-1.66; P = .243) or LCR (HR 1.28; CI .93-1.78; P = .130), but was associated with a significant increase in the risk of CR (HR 1.91; CI 1.49-2.46; P < .001). Borderline ischemia (SDS = 1), compared to no ischemia (SDS = 0), was not associated with a significant difference in the risk of CD/MI [HR 1.09; CI .70-1.69; P = .693], but was associated with a significant increase in the risk of CR (HR 5.62; CI 3.08-10.25; P < .001) and LCR (HR 2.98; CI 1.36-6.53; P = .006).
Conclusion
Near-normal MPI and borderline ischemia on SPECT-MPI provide no significant prognostic information in predicting hard cardiac events but are associated with higher rates of obstructive angiographic CAD and coronary revascularizations.



J Nucl Cardiol: 08 Oct 2020; epub ahead of print
Kassab K, Hussain K, Torres A, Iskander F, ... Khan R, Doukky R
J Nucl Cardiol: 08 Oct 2020; epub ahead of print | PMID: 33034835
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Impact:
Abstract

The prognostic implications of ST-segment and T-wave abnormalities in patients undergoing regadenoson stress SPECT myocardial perfusion imaging.

Khan MS, Arif AW, Doukky R
Background
The prognostic implications of ST-segment and T-wave (ST/T) abnormalities in patients undergoing stress SPECT-myocardial perfusion imaging (MPI) are not well defined.
Methods and results
This was a single-center, retrospective cohort study of consecutive patients who underwent regadenoson stress SPECT-MPI. Patients with baseline electrocardiogram (ECG) abnormalities that impede ST/T analysis or those with known coronary artery disease were excluded. Patients were categorized as having primary ST abnormalities, secondary ST/T abnormalities due to ventricular hypertrophy or right bundle branch block, T-wave abnormalities, or normal ECG. The primary outcome was major adverse cardiovascular events (MACE) defined as the composite of cardiac death or myocardial infarction. Among 6,059 subjects, 1912 (32%) had baseline ST/T abnormalities. During a mean follow-up of 2.3 ± 1.9 years, the incidence of MACE was significantly higher among patients with secondary ST/T abnormalities compared to those with normal ECG (HR 2.05; 95% confidence interval [CI], 1.04-4.05; P = 0.039). No significant difference in MACE was observed among patients with primary ST abnormalities (HR 1.64; CI 0.87-3.06; P = 0.124) or T-wave abnormalities (HR 1.15; CI 0.62-2.16; P = 0.658) compared with patients who had normal ECG. Among patients with secondary ST/T changes, abnormal MPI was not associated with a significant increase in MACE rates compared to normal MPI (HR 1.18; CI 0.31-4.58; P = 0.808). However, abnormal MPI was associated with higher MACE rates among patients with primary ST abnormalities (HR 4.50; CI 1.44-14.10; P = 0.005) and T-wave abnormalities (HR 3.74; CI 1.20-11.68; P = 0.015). Similarly, myocardial ischemia on regadenoson stress SPECT-MPI was not associated with a significant increase in MACE rates in patients with secondary ST/T abnormalities (HR 1.45; CI 0.38-5.61; P = 0.588), while it was associated with a higher incidence of MACE in patients with primary ST abnormalities (HR 3.012; CI 0.95-9.53; P = 0.049) and T-wave abnormalities (HR 5.06; CI 1.60-15.96; P = 0.002).
Conclusion
While patients with secondary ST/T abnormalities had significantly higher MACE risk, abnormal MPI or presence of myocardial ischemia on regadenoson SPECT-MPI in this group does not add prognostic information. Patients with primary ST abnormalities and T-wave abnormalities do not seem to have a significantly higher MACE risk compared to those with normal ECG; however, abnormal MPI or presence of myocardial ischemia, in these groups, correlates with higher MACE rates.



J Nucl Cardiol: 07 Oct 2020; epub ahead of print
Khan MS, Arif AW, Doukky R
J Nucl Cardiol: 07 Oct 2020; epub ahead of print | PMID: 33034037
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Impact:
Abstract

Anger recall mental stress decreases I-metaiodobenzylguanidine (I-MIBG) uptake and increases heterogeneity of cardiac sympathetic activity in the myocardium in patients with ischemic cardiomyopathy.

Avendaño R, Hashemi-Zonouz T, Sandoval V, Liu C, ... Lampert R, Liu YH
Background
Acute psychological stressors such as anger can precipitate ventricular arrhythmias, but the mechanism is incompletely understood. Quantification of regional myocardial sympathetic activity with I-metaiodobenzylguanidine (I-mIBG) SPECT imaging in conjunction with perfusion imaging during mental stress may identify a mismatch between perfusion and sympathetic activity that may exacerbate a mismatch between perfusion and sympathetic activity that could create a milieu of increased vulnerability to ventricular arrhythmia.
Methods
Five men with ischemic cardiomyopathy (ICM), and five age-matched healthy male controls underwent serial I-mIBG and Tc-Tetrofosmin SPECT/CT imaging during an anger recall mental stress task and dual isotope imaging was repeated approximately 1 week later during rest. Images were reconstructed using an iterative reconstruction algorithm with CT-based attenuation correction. The mismatch of left ventricular myocardial I-mIBG and Tc-Tetrofosmin was assessed along with radiotracer heterogeneity and the I-mIBG heart-to-mediastinal ratios (HMR) were calculated using custom software developed at Yale.
Results
The hemodynamic response to mental stress was similar in both groups. The resting-HMR was greater in healthy control subjects (3.67 ± 0.95) than those with ICM (3.18 ± 0.68, P = .04). Anger recall significantly decreased the HMR in ICM patients (2.62 ± 0.3, P = .04), but not in normal subjects. The heterogeneity of I-mIBG uptake in the myocardium was significantly increased in ICM patients during mental stress (26% ± 8.23% vs. rest: 19.62% ± 9.56%; P = .01), whereas the Tc-Tetrofosmin uptake pattern was unchanged.
Conclusion
Mental stress decreased the I-mIBG HMR, increased mismatch between sympathetic activity and myocardial perfusion, and increased the heterogeneity of I-mIBG uptake in ICM patients, while there was no significant change in myocardial defect size or the heterogeneity of Tc-Tetrofosmin perfusion. The changes observed in this proof-of-concept study may provide valuable information about the trigger-substrate interaction and the potential vulnerability for ventricular arrhythmias.



J Nucl Cardiol: 07 Oct 2020; epub ahead of print
Avendaño R, Hashemi-Zonouz T, Sandoval V, Liu C, ... Lampert R, Liu YH
J Nucl Cardiol: 07 Oct 2020; epub ahead of print | PMID: 33034036
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Impact:
Abstract

Mortality risk among patients undergoing exercise versus pharmacologic myocardial perfusion imaging: A propensity-based comparison.

Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson L, Berman DS
Background
The increased risk associated with pharmacologic versus exercise testing is obscured by the higher prevalence of clinical risk factors among pharmacologic patients. Thus, we assessed comparative mortality in a large risk factor-matched group of exercise versus pharmacologic patients undergoing stress/rest SPECT myocardial perfusion imaging (MPI).
Methods
39,179 patients undergoing stress/rest SPECT-MPI were followed for 13.3 ± 5.0 years for all-cause mortality (ACM). We applied propensity-matching to create pharmacologic and exercise groups with similar risk profiles.
Results
In comparison to exercise patients, pharmacologic patients had an increased risk-adjusted hazard ratio for ACM for each level of ischemia: increased by 3.8-fold (95%CI 3.5-4.1) among nonischemic patients, 2.5-fold (95%CI 2.0-3.2) among mildly ischemic patients, and 2.6-fold (95%CI 2.1-3.3) among moderate/severe ischemic patients. Similar findings were observed among a propensity-matched cohort of 10,113 exercise and 10,113 pharmacologic patients as well as in an additional cohort that also excluded patients with noncardiac co-morbidities.
Conclusions
Patients requiring pharmacologic stress testing manifest substantially heightened clinical risk at each level of myocardial ischemia and even when myocardial ischemia is absent. These findings suggest the need to study the pathophysiological drivers of increased risk in association with pharmacologic testing and to convey this risk in clinical reports.



J Nucl Cardiol: 11 Oct 2020; epub ahead of print
Rozanski A, Gransar H, Hayes SW, Friedman JD, Thomson L, Berman DS
J Nucl Cardiol: 11 Oct 2020; epub ahead of print | PMID: 33047282
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Impact:
Abstract

Normal myocardial perfusion despite a very high coronary calcium score.

Castro-Villacorta H, Ortiz-Velázquez JF, Preciado-Gutiérrez OU, Paz-Gómez R, Alemán-Villalobos R, Preciado-Anaya A

An exceptionally high coronary calcium score, greater than 10,000 UA, superior to any other found in the literature reviewed, was reported in an asymptomatic, adult man with hypertension, obesity and dyslipidemia, without myocardial ischemia and no significative coronary stenosis, associated to Glagov\'s phenomenon in the left coronary artery and an abdominal aortic aneurysm.



J Nucl Cardiol: 11 Oct 2020; epub ahead of print
Castro-Villacorta H, Ortiz-Velázquez JF, Preciado-Gutiérrez OU, Paz-Gómez R, Alemán-Villalobos R, Preciado-Anaya A
J Nucl Cardiol: 11 Oct 2020; epub ahead of print | PMID: 33047281
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Impact:
Abstract

Incremental prognostic value of hybrid [15O]H2O positron emission tomography-computed tomography: combining myocardial blood flow, coronary stenosis severity, and high-risk plaque morphology.

Driessen RS, Bom MJ, van Diemen PA, Schumacher SP, ... Danad I, Knaapen P
Aims 
This study sought to determine the prognostic value of combined functional testing using positron emission tomography (PET) perfusion imaging and anatomical testing using coronary computed tomography angiography (CCTA)-derived stenosis severity and plaque morphology in patients with suspected coronary artery disease (CAD).
Methods and results 
In this retrospective study, 539 patients referred for hybrid [15O]H2O PET-CT imaging because of suspected CAD were investigated. PET was used to determine myocardial blood flow (MBF), whereas CCTA images were evaluated for obstructive stenoses and high-risk plaque (HRP) morphology. Patients were followed up for the occurrence of all-cause death and non-fatal myocardial infarction (MI). During a median follow-up of 6.8 (interquartile range 4.8-7.8) years, 42 (7.8%) patients experienced events, including 23 (4.3%) deaths, and 19 (3.5%) MIs. Annualized event rates for normal vs. abnormal results of PET MBF, CCTA-derived stenosis, and HRP morphology were 0.6 vs. 2.1%, 0.4 vs. 2.1%, and 0.8 vs. 2.8%, respectively (P < 0.001 for all). Cox regression analysis demonstrated prognostic values of PET perfusion imaging [hazard ratio (HR) 3.75 (1.84-7.63), P < 0.001], CCTA-derived stenosis [HR 5.61 (2.36-13.34), P < 0.001], and HRPs [HR 3.37 (1.83-6.18), P < 0.001] for the occurrence of death or MI. However, only stenosis severity [HR 3.01 (1.06-8.54), P = 0.039] and HRPs [HR 1.93 (1.00-3.71), P = 0.049] remained independently associated.
Conclusion 
PET-derived MBF, CCTA-derived stenosis severity, and HRP morphology were univariably associated with death and MI, whereas only stenosis severity and HRP morphology provided independent prognostic value.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1105-1113
Driessen RS, Bom MJ, van Diemen PA, Schumacher SP, ... Danad I, Knaapen P
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1105-1113 | PMID: 32959061
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Abstract

Shear Wave Elastography Using High-Frame-Rate Imaging in the Follow-Up of Heart Transplantation Recipients.

Petrescu A, Bézy S, Cvijic M, Santos P, ... D\'hooge J, Voigt JU
Objectives
The purpose of this study was to investigate whether propagation velocities of naturally occurring shear waves (SWs) at mitral valve closure (MVC) increase with the degree of diffuse myocardial injury (DMI) and with invasively determined LV filling pressures as a reflection of an increase in myocardial stiffness in heart transplantation (HTx) recipients.
Background
After orthotopic HTx, allografts undergo DMI that contributes to functional impairment, especially to increased passive myocardial stiffness, which is an important pathophysiological determinant of left ventricular (LV) diastolic dysfunction. Echocardiographic SW elastography is an emerging approach for measuring myocardial stiffness in vivo. Natural SWs occur after mechanical excitation of the myocardium, for example, after MVC, and their propagation velocity is directly related to myocardial stiffness, thus providing an opportunity to assess myocardial stiffness at end-diastole.
Methods
52 HTx recipients that underwent right heart catheterization (all) and cardiac magnetic resonance (CMR) (n = 23) during their annual check-up were prospectively enrolled. Echocardiographic SW elastography was performed in parasternal long axis views of the LV using an experimental scanner at 1,135 ± 270 frames per second. The degree of DMI was quantified with T1 mapping.
Results
SW velocity at MVC correlated best with native myocardial T1 values (r = 0.75; p < 0.0001) and was the best noninvasive parameter that correlated with pulmonary capillary wedge pressures (PCWP) (r = 0.54; p < 0.001). Standard echocardiographic parameters of LV diastolic function correlated poorly with both native T1 and PCWP values.
Conclusions
End-diastolic SW propagation velocities, as measure of myocardial stiffness, showed a good correlation with CMR-defined diffuse myocardial injury and with invasively determined LV filling pressures in patients with HTx. Thus, these findings suggest that SW elastography has the potential to become a valuable noninvasive method for the assessment of diastolic myocardial properties in HTx recipients.

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

JACC Cardiovasc Imaging: 27 Sep 2020; epub ahead of print
Petrescu A, Bézy S, Cvijic M, Santos P, ... D'hooge J, Voigt JU
JACC Cardiovasc Imaging: 27 Sep 2020; epub ahead of print | PMID: 33004291
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Impact:
Abstract

Predictive value of left ventricular diastolic chamber stiffness in patients with severe aortic stenosis undergoing aortic valve replacement.

Anand V, Adigun RO, Thaden JT, Pislaru SV, ... Greason KL, Pislaru C
Aims
Despite improvements in cardiac haemodynamics and symptoms, long-term mortality remains increased in some patients after aortic valve replacement (AVR). Limited data exist on the prognostic role of left ventricular (LV) chamber stiffening in these patients.
Methods and results
We performed a retrospective analysis in 1893 patients with severe aortic stenosis (AS) referred for AVR. LV end-diastolic pressure-volume relations (EDPVR, P = αV^β) were reconstructed from echocardiographic measurements of end-diastolic volumes and estimates of end-diastolic pressure (EDP). The impact of EDPVR-derived LV chamber stiffness (CS30, at 30 mmHg EDP) on all-cause mortality after AVR was evaluated. Mean age was 76 ± 10 years, 39% were females, and ejection fraction (EF) was 61 ± 12%. The mean LV chamber stiffness (CS30) was 2.2 ± 1.3 mmHg/mL. A total of 877 (46%) patients had high LV stiffness (CS30 >2 mmHg/mL). In these patients, the EDPVR curves were steeper and shifted leftwards, indicating higher stiffness at all pressure levels. These patients were slightly older, more often female, and had more prevalent comorbidities compared to patients with low stiffness. At follow-up [median 4.2 (interquartile range 2.8-6.3) years; 675 deaths], a higher CS30 was associated with lower survival (hazard ratio: 2.7 for severe vs. mild LV stiffening; P < 0.0001), both in patients with normal or reduced EF. At multivariate analysis, CS30 remained an independent predictor, even after adjusting for age, sex, comorbidities, EF, LV remodelling, and diastolic dysfunction.
Conclusion
Higher preoperative LV chamber stiffening in patients with severe AS is associated with poorer outcome despite successful AVR.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1160-1168
Anand V, Adigun RO, Thaden JT, Pislaru SV, ... Greason KL, Pislaru C
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1160-1168 | PMID: 31776545
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Impact:
Abstract

Reclassification of prosthesis-patient mismatch after transcatheter aortic valve replacement using predicted vs. measured indexed effective orifice area.

Ternacle J, Guimaraes L, Vincent F, Côté N, ... Pibarot P, Rodés-Cabau J
Aims
The objective was to compare the incidence and impact on outcomes of measured (PPMM) vs. predicted (PPMP) prosthesis-patient mismatch following transcatheter aortic valve replacement (TAVR).
Methods and results
All consecutives patients who underwent TAVR between 2007 and 2018 were included. Effective orifice area (EOA) was measured by Doppler-echocardiography using the continuity equation and predicted according to the normal reference for each model and size of valve. PPM was defined using EOA indexed (EOAi) to body surface area as moderate if ≤0.85 cm2/m2 and severe if ≤ 0.65 cm2/m2 (respectively, ≤ 0.70 and ≤ 0.55 cm2/m2 if body mass index ≥ 30 kg/m2). The outcome endpoints were high residual gradient (≥20 mmHg) and the composite of cardiovascular mortality and hospital readmission for heart failure at 1 year. Overall, 1088 patients underwent a TAVR (55% male, age 79.1 ± 8.4 years, and STS score 6.6 ± 4.7%); balloon-expandable device was used in 83%. Incidence of moderate (10% vs. 27%) and severe (1% vs. 17%) PPM was markedly lower when defined by predicted vs. measured EOAi (P < 0.001). Balloon-expandable device implantation (OR: 1.90, P = 0.029) and valve-in-valve procedure (n = 118; OR: 3.21, P < 0.001) were the main factors associated with PPM occurrence. Compared with measured PPM, predicted PPM showed stronger association with high residual gradient. Severe measured or predicted PPM was not associated with clinical outcomes.
Conclusion
The utilization of the predicted EOAi reclassifies the majority of patients with PPM to no PPM following TAVR. Compared with measured PPM, predicted PPM had stronger association with haemodynamic outcomes, while both methods were not associated with clinical outcomes.

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

Eur Heart J Cardiovasc Imaging: 29 Sep 2020; epub ahead of print
Ternacle J, Guimaraes L, Vincent F, Côté N, ... Pibarot P, Rodés-Cabau J
Eur Heart J Cardiovasc Imaging: 29 Sep 2020; epub ahead of print | PMID: 32995865
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Impact:
Abstract

Cardiovascular disease in women: insights from magnetic resonance imaging.

Bucciarelli-Ducci C, Ostenfeld E, Baldassarre LA, Ferreira VM, ... Valente AM, Ordovas KG

The presentation and identification of cardiovascular disease in women pose unique diagnostic challenges compared to men, and underrecognized conditions in this patient population may lead to clinical mismanagement.This article reviews the sex differences in cardiovascular disease, explores the diagnostic and prognostic role of cardiovascular magnetic resonance (CMR) in the spectrum of cardiovascular disorders in women, and proposes the added value of CMR compared to other imaging modalities. In addition, this article specifically reviews the role of CMR in cardiovascular diseases occurring more frequently or exclusively in female patients, including Takotsubo cardiomyopathy, connective tissue disorders, primary pulmonary arterial hypertension and peripartum cardiomyopathy. Gaps in knowledge and opportunities for further investigation of sex-specific cardiovascular differences by CMR are also highlighted.



J Cardiovasc Magn Reson: 27 Sep 2020; 22:71
Bucciarelli-Ducci C, Ostenfeld E, Baldassarre LA, Ferreira VM, ... Valente AM, Ordovas KG
J Cardiovasc Magn Reson: 27 Sep 2020; 22:71 | PMID: 32981527
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Abstract

Detection of subclinical myocardial dysfunction in cocaine addicts with feature tracking cardiovascular magnetic resonance.

Maceira AM, Guardiola S, Ripoll C, Cosin-Sales J, Belloch V, Salazar J
Background
Cocaine is an addictive, sympathomimetic drug with potentially lethal effects. We have previously shown with cardiovascular magnetic resonance (CMR) the presence of cardiovascular involvement in a significant percentage of consecutive asymptomatic cocaine addicts. CMR with feature-tracking analysis (CMR-FT) allows for the quantification of myocardial deformation which may detect preclinical involvement. Therefore, we aimed to assess the effects of cocaine on the left ventricular myocardium in a group of asymptomatic cocaine users with CMR-FT.
Methods
In a cohort of asymptomatic cocaine addicts (CA) who had been submitted to CMR at 3 T, we used CMR-FT to measure strain, strain rate and dyssynchrony index in CA with mildly decreased left ventricular ejection fraction (CA-LVEF) and in CA with preserved ejection fraction (CA-LVEF). We also measured these parameters in 30 age-matched healthy subjects.
Results
There were no differences according to age. Significant differences were seen in global longitudinal, radial and circumferential strain, in global longitudinal and radial strain rate and in radial and circumferential dyssynchrony index among the groups, with the lowest values in CA-LVEF and intermediate values in CA-LVEF. Longitudinal, radial and circumferential strain values were significantly lower in CA-LVEF with respect to controls.
Conclusions
CA-LVEF show decreased systolic strain and strain rate values, with intermediate values between healthy controls and CA-LVEF. Signs suggestive of dyssynchrony were also detected. In CA, CMR-FT based strain analysis can detect early subclinical myocardial involvement.



J Cardiovasc Magn Reson: 27 Sep 2020; 22:70
Maceira AM, Guardiola S, Ripoll C, Cosin-Sales J, Belloch V, Salazar J
J Cardiovasc Magn Reson: 27 Sep 2020; 22:70 | PMID: 32981526
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Impact:
Abstract

Impact of three-dimensional global longitudinal strain for patients with acute myocardial infarction.

Iwahashi N, Kirigaya J, Abe T, Horii M, ... Tamura K, Kimura K
Aims
In patients with ST-segment elevation myocardial infarction (STEMI), predicting left ventricular (LV) remodelling (LVR) and prognosis is important. We explored the clinical usefulness of three-dimensional (3D) speckle-tracking echocardiography to predict LVR and prognosis in STEMI.
Methods and results
The study group comprised 255 first STEMI patients (65 years; 210 men) treated with primary percutaneous coronary intervention between April 2008 and May 2012 at Yokohama City University Medical Center. Baseline global longitudinal strain (GLS) was measured with two-dimensional (2D) and 3D speckle-tracking echocardiography. Within 48 of admission, standard 2D echocardiography and 3D full-volume imaging were performed, and 2D-GLS and 3D-GLS were calculated. Infarct size was estimated by 99mTc-sestamibi single-photon emission computed tomography. Echocardiography was performed at 1 year repeatedly in 239 patients. The primary endpoint was LVR, defined as an increase of 20% of LV end-diastolic volume index and major adverse cardiac and cerebrovascular events (MACE: cardiac death, non-fatal MI, heart failure, and ischaemic stroke) at 1 year, and the secondary endpoint was cardiac death and heart failure. Patients were followed for 1 year; 64, 25, and 16 patients experienced LVR, MACE, and the secondary endpoint, respectively. Multivariate analysis revealed that 3D-GLS was the strongest predictor of LVR (odds ratio = 1.437, 95% CI: 1.047-2.257, P = 0.02), MACE (odds ratio = 1.443, 95% CI: 1.240-1.743, P = 0.0002), and the secondary end point (odds ratio = 1.596, 95% CI: 1.17-1.56, P < 0.0001). Receiver-operating characteristic curve analysis showed that 3D-GLS was superior to 2D-GLS in predicting LVR and 1-year prognosis.
Conclusion
3D-GLS obtained immediately after STEMI is independently associated with LVR and 1-year prognosis.

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

Eur Heart J Cardiovasc Imaging: 29 Sep 2020; epub ahead of print
Iwahashi N, Kirigaya J, Abe T, Horii M, ... Tamura K, Kimura K
Eur Heart J Cardiovasc Imaging: 29 Sep 2020; epub ahead of print | PMID: 32995886
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Impact:
Abstract

Cardiac-MRI Predicts Clinical Worsening and Mortality in Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis.

Alabed S, Shahin Y, Garg P, Alandejani F, ... Kiely DG, Swift AJ
Objectives
This meta-analysis evaluates assessment of pulmonary arterial hypertension (PAH), with a focus on clinical worsening and mortality.
Background
Cardiac magnetic resonance (CMR) has prognostic value in the assessment of patients with PAH. However, there are limited data on the prediction of clinical worsening, an important composite endpoint used in PAH therapy trials.
Methods
The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Web of Science databases were searched in May 2020. All CMR studies assessing clinical worsening and the prognosis of patients with PAH were included. Pooled hazard ratios of univariate regression analyses for CMR measurements, for prediction of clinical worsening and mortality, were calculated.
Results
Twenty-two studies with 1,938 participants were included in the meta-analysis. There were 18 clinical worsening events and 8 deaths per 100 patient-years. The pooled hazard ratios show that every 1% decrease in right ventricular (RV) ejection fraction is associated with a 4.9% increase in the risk of clinical worsening over 22 months of follow-up and a 2.2% increase in the risk of death over 54 months. For every 1 ml/m increase in RV end-systolic volume index or RV end-diastolic volume index, the risk of clinical worsening increases by 1.3% and 0.7%, respectively, and the risk of mortality increases by 0.9% and 1%. Every 1 ml/m decrease in left ventricular end-systolic volume index or left ventricular end-diastolic volume index increased the risk of death by 2.1% and 2.3%. Left ventricular parameters were not associated with clinical worsening.
Conclusions
This review confirms CMR as a powerful prognostic marker in PAH in a large cohort of patients. In addition to confirming previous observations that RV function and RV and left ventricular volumes predict mortality, RV function and volumes also predict clinical worsening. This study provides a strong rationale for considering CMR as a clinically relevant endpoint for trials of PAH therapies.

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

JACC Cardiovasc Imaging: 28 Sep 2020; epub ahead of print
Alabed S, Shahin Y, Garg P, Alandejani F, ... Kiely DG, Swift AJ
JACC Cardiovasc Imaging: 28 Sep 2020; epub ahead of print | PMID: 33008758
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Impact:
Abstract

The Clinical Spectrum of Myocardial Infarction and Ischemia With Nonobstructive Coronary Arteries in Women.

van den Hoogen IJ, Gianni U, Wood MJ, Taqueti VR, ... Shaw LJ,

Women exhibit less burden of anatomic obstructive coronary atherosclerotic disease as compared with men of the same age, but contradictorily show similar or higher cardiovascular mortality rates. The higher prevalence of nonexertional cardiac symptoms and nonobstructive coronary atherosclerotic disease in women may lead to lack of recognition and appropriate management, resulting in undertesting and undertreatment. Leaders in women\'s health from the American College of Cardiology\'s Cardiovascular Disease in Women Committee present novel imaging cases that may provoke thought regarding the broad clinical spectrum of myocardial infarction and ischemia with nonobstructive coronary arteries in women. These unique imaging approaches are based on the concept of targeting sex-specific differences in acute and stable ischemic heart disease.

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

JACC Cardiovasc Imaging: 25 Sep 2020; epub ahead of print
van den Hoogen IJ, Gianni U, Wood MJ, Taqueti VR, ... Shaw LJ,
JACC Cardiovasc Imaging: 25 Sep 2020; epub ahead of print | PMID: 33011128
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Impact:
Abstract

Hypertensive Exposure Markers by MRI in Relation to Cerebral Small Vessel Disease and Cognitive Impairment.

Amier RP, Marcks N, Hooghiemstra AM, Nijveldt R, ... van Rossum AC,
Objectives
This study sought to investigate the extent of hypertensive exposure as assessed by cardiovascular magnetic resonance imaging (MRI) in relation to cerebral small vessel disease (CSVD) and cognitive impairment, with the aim of understanding the role of hypertension in the early stages of deteriorating brain health.
Background
Preserving brain health into advanced age is one of the great challenges of modern medicine. Hypertension is thought to induce vascular brain injury through exposure of the cerebral microcirculation to increased pressure/pulsatility. Cardiovascular MRI provides markers of (subclinical) hypertensive exposure, such as aortic stiffness by pulse wave velocity (PWV), left ventricular (LV) mass index (LVMi), and concentricity by mass-to-volume ratio.
Methods
A total of 559 participants from the Heart-Brain Connection Study (431 patients with manifest cardiovascular disease and 128 control participants), age 67.8 ± 8.8 years, underwent 3.0-T heart-brain MRI and extensive neuropsychological testing. Aortic PWV, LVMi, and LV mass-to-volume ratio were evaluated in relation to presence of CSVD and cognitive impairment. Effect modification by patient group was investigated by interaction terms; results are reported pooled or stratified accordingly.
Results
Aortic PWV (odds ratio [OR]: 1.17; 95% confidence interval [CI]: 1.05 to 1.30 in patient groups only), LVMi (in carotid occlusive disease, OR: 5.69; 95% CI: 1.63 to 19.87; in other groups, OR: 1.30; 95% CI: 1.05 to 1.62]) and LV mass-to-volume ratio (OR: 1.81; 95% CI: 1.46 to 2.24) were associated with CSVD. Aortic PWV (OR: 1.07; 95% CI: 1.02 to 1.13) and LV mass-to-volume ratio (OR: 1.27; 95% CI: 1.07 to 1.51) were also associated with cognitive impairment. Relations were independent of sociodemographic and cardiac index and mostly persisted after correction for systolic blood pressure or medical history of hypertension. Causal mediation analysis showed significant mediation by presence of CSVD in the relation between hypertensive exposure markers and cognitive impairment.
Conclusions
The extent of hypertensive exposure is associated with CSVD and cognitive impairment beyond clinical blood pressure or medical history. The mediating role of CSVD suggests that hypertension may lead to cognitive impairment through the occurrence of CSVD.

Copyright © 2020. Published by Elsevier Inc.

JACC Cardiovasc Imaging: 27 Sep 2020; epub ahead of print
Amier RP, Marcks N, Hooghiemstra AM, Nijveldt R, ... van Rossum AC,
JACC Cardiovasc Imaging: 27 Sep 2020; epub ahead of print | PMID: 33011127
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Impact:
Abstract

Assessment of Multivessel Coronary Artery Disease Using Cardiovascular Magnetic Resonance Pixelwise Quantitative Perfusion Mapping.

Kotecha T, Chacko L, Chehab O, O\'Reilly N, ... Patel N, Fontana M
Objectives
The authors sought to compare the diagnostic accuracy of quantitative perfusion maps to visual assessment (VA) of first-pass perfusion images for the detection of multivessel coronary artery disease (MVCAD).
Background
VA of first-pass stress perfusion cardiac magnetic resonance (CMR) may underestimate ischemia in MVCAD. Pixelwise perfusion mapping allows quantitative measurement of regional myocardial blood flow, which may improve ischemia detection in MVCAD.
Methods
One hundred fifty-one subjects recruited at 2 centers underwent stress perfusion CMR with myocardial perfusion mapping, and invasive coronary angiography with coronary physiology assessment. Ischemic burden was assessed by VA of first-pass images and by quantitative measurement of stress myocardial blood flow using perfusion maps.
Results
In patients with MVCAD (2-vessel [2VD] or 3-vessel disease [3VD]; n = 95), perfusion mapping identified significantly more segments with perfusion defects (median segments per patient 12 [interquartile range (IQR): 9 to 16] by mapping vs. 8 [IQR: 5 to 9.5] by VA; p < 0.001). Ischemic burden (IB) measured using mapping was higher in MVCAD compared with IB measured using VA (3VD mapping 100 % (75% to 100%) vs. first-pass 56% (38% to 81%) ; 2VD mapping 63% (50% to 75%) vs. first-pass 41% (31% to 50%); both p < 0.001), but there was no difference in single-vessel disease (mapping 25% (13% to 44%) vs. 25% (13% to 31%). Perfusion mapping was superior to VA for the correct identification of extent of coronary disease (78% vs. 58%; p < 0.001) due to better identification of 3VD (87% vs. 40%) and 2VD (71% vs. 48%).
Conclusions
VA of first-pass stress perfusion underestimates ischemic burden in MVCAD. Pixelwise quantitative perfusion mapping increases the accuracy of CMR in correctly identifying extent of coronary disease. This has important implications for assessment of ischemia and therapeutic decision-making.

Copyright © 2020 American College of Cardiology Foundation. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2020; epub ahead of print
Kotecha T, Chacko L, Chehab O, O'Reilly N, ... Patel N, Fontana M
JACC Cardiovasc Imaging: 29 Sep 2020; epub ahead of print | PMID: 33011115
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Impact:
Abstract

Predictors of Rapid Plaque Progression: An Optical Coherence Tomography Study.

Araki M, Yonetsu T, Kurihara O, Nakajima A, ... Kakuta T, Jang IK
Objectives
This study sought to identify morphological predictors of rapid plaque progression.
Background
Two patterns of plaque progression have been described: slow linear progression and rapid step-wise progression. The former pattern will cause stable angina when the narrowing reaches a critical threshold, whereas the latter pattern may lead to acute coronary syndromes or sudden cardiac death.
Methods
Patients who underwent optical coherence tomography (OCT) imaging during the index procedure and follow-up angiography with a minimum interval of 6 months were selected. Nonculprit lesions with a diameter stenosis of ≥30% on index angiography were assessed. Lesion progression was defined as a decrease of angiographic minimum lumen diameter ≥0.4 mm at follow-up (mean, 7.1 months). Baseline morphological characteristics of plaques with rapid progression were evaluated by OCT. In a subgroup with follow-up OCT imaging for plaques with rapid progression, morphological changes from baseline to follow-up were assessed.
Results
Among 517 lesions in 248 patients, 50 lesions showed rapid progression. These lesions had a significantly higher prevalence of lipid-rich plaque (76.0% vs. 50.5%, respectively), thin-cap fibroatheroma (TCFA) (20.0% vs. 5.8%, respectively), layered plaque (60.0% vs. 34.0%, respectively), macrophage accumulation (62.0% vs. 42.4%, respectively), microvessel (46.0% vs. 29.1%, respectively), plaque rupture (12.0% vs. 4.7%, respectively), and thrombus (6.0% vs. 1.1%, respectively) at baseline compared with those without rapid progression. Multivariate analysis identified lipid-rich plaque (odds ratio [OR]: 2.17; 95% confidence interval [CI]: 1.02 to 4.62; p = 0.045]), TCFA (OR: 5.85; 95% CI: 2.01 to 17.03; p = 0.001), and layered plaque (OR: 2.19; 95% CI: 1.03 to 4.17; p = 0.040) as predictors of subsequent rapid lesion progression. In a subgroup analysis for plaques with rapid progression, a new layer was detected in 25 of 41 plaques (61.0%) at follow-up.
Conclusions
Lipid-rich plaques, TCFA, and layered plaques were predictors of subsequent rapid plaque progression. A new layer, a signature of previous plaque disruption and healing, was detected in more than half of the lesions with rapid progression at follow-up. (Massachusetts General Hospital Optical Coherence Tomography Registry; NCT01110538).

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

JACC Cardiovasc Imaging: 28 Sep 2020; epub ahead of print
Araki M, Yonetsu T, Kurihara O, Nakajima A, ... Kakuta T, Jang IK
JACC Cardiovasc Imaging: 28 Sep 2020; epub ahead of print | PMID: 33011121
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Impact:
Abstract

Effect of Ticagrelor on Left Ventricular Remodeling in Patients With ST-Segment Elevation Myocardial Infarction (HEALING-AMI).

Park Y, Koh JS, Lee JH, Park JH, ... Jeong YH,
Objectives
The aim of this study was to evaluate the effect of ticagrelor versus clopidogrel on left ventricular (LV) remodeling after reperfusion of ST-segment elevation myocardial infarction (STEMI) in humans.
Background
Animal studies have demonstrated that ticagrelor compared with clopidogrel better protects myocardium against reperfusion injury and improves remodeling after myocardial infarction.
Methods
In this investigator-initiated, randomized, open-label, assessor-blinded trial performed at 10 centers in Korea, patients were enrolled if they had naive STEMI successfully treated with primary percutaneous coronary intervention (PCI) and at least 6-month planned duration of dual-antiplatelet treatment. The coprimary endpoints were LV remodeling index (LVRI) (a relative change of LV end-diastolic volume) measured on 3-dimensional echocardiography and N-terminal pro-B-type natriuretic peptide level at 6 months.
Results
Among initially enrolled patients with STEMI (n = 336), 139 in each group completed the study. LVRI at 6 months was numerically lower with ticagrelor versus clopidogrel (0.6 ± 18.6% vs. 4.5 ± 16.5%; p = 0.095). Ticagrelor significantly reduced the 6-month level of N-terminal pro-B-type natriuretic peptide (173 ± 141 pg/ml vs. 289 ± 585 pg/ml; p = 0.028). These differences were prominent in patients with pre-PCI TIMI (Thrombolysis In Myocardial Infarction) flow grade 0. By multivariate analysis, ticagrelor versus clopidogrel reduced the risk for positive LV remodeling (LVRI >0%) (odds ratio: 0.56; 95% confidence interval: 0.33 to 0.95; p = 0.030). The LV end-diastolic volume index remained unchanged during ticagrelor treatment (from 54.7 ± 12.2 to 54.2 ± 12.2 ml/m; p = 0.629), but this value increased over time during clopidogrel treatment (from 54.6 ± 11.3 to 56.4 ± 13.9 ml/m; p = 0.056) (difference -2.3 ml/m; 95% confidence interval: -4.8 to 0.2 ml/m; p = 0.073). Ticagrelor reduced LV end-systolic volume index (from 27.0 ± 8.5 to 24.7 ± 8.4 ml/m; p < 0.001), whereas no reduction was seen with clopidogrel (from 26.2 ± 8.9 to 25.6 ± 11.0 ml/m; p = 0.366) (difference -1.8 ml/m; 95% confidence interval: -3.5 to -0.1 ml/m; p = 0.040).
Conclusions
Ticagrelor was superior to clopidogrel for LV remodeling after reperfusion of STEMI with primary PCI. (High Platelet Inhibition With Ticagrelor to Improve Left Ventricular Remodeling in Patients With ST Segment Elevation Myocardial Infarction [HEALING-AMI]; NCT02224534).

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

JACC Cardiovasc Interv: 11 Oct 2020; 13:2220-2234
Park Y, Koh JS, Lee JH, Park JH, ... Jeong YH,
JACC Cardiovasc Interv: 11 Oct 2020; 13:2220-2234 | PMID: 33032710
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Impact:
Abstract

Influence of prosthesis-related factors on the occurrence of early leaflet thrombosis after transcatheter aortic valve implantation.

Breitbart P, Pache G, Minners J, Hein M, ... Neumann FJ, Ruile P
Aims
Early leaflet thrombosis (LT) is a well-described phenomenon after transcatheter aortic valve implantation (TAVI) with an incidence around 15%. Data about predictors of LT are scarce. The purpose of the study was to investigate the influence of prosthesis-related factors on the occurrence of LT.
Materials and results
Fusion imaging of pre- and post-procedural computed tomography angiography was performed in 55 TAVI patients with LT and 140 selected patients as control groups (85 patients in an unmatched and 55 in a matched control) to obtain a 3D reconstruction of the transcatheter heart valve (THV) within the native annulus region. All patients received a balloon-expandable Sapien 3 THV. The THV length above and below the native annulus was measured within the fused images to assess the implantation depth. The deployed THV area was quantified on three heights (left ventricular outflow tract end, stent centre, and aortic end) to determine the average expansion of the prosthesis as percent of the nominal area. We also calculated the extent of prosthesis waist in percent of maximum area. After multivariate adjustment, the extent of THV waist [odds ratio (OR) per 10% (confidence interval, CI) 0.636 (0.526-0.769), P < 0.001] as prosthesis-related factor and previous oral anticoagulation [OR (CI) 0.070 (0.020-0.251), P < 0.001] had significant, independent influence on the occurrence of LT. The implantation depth showed no influence on LT manifestation (P = 0.704).
Conclusion
Besides the absence of previous oral anticoagulation, a less pronounced waist of the implanted THV was a prosthesis-position-related independent predictor of LT after TAVI using the Sapien 3.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1082-1089
Breitbart P, Pache G, Minners J, Hein M, ... Neumann FJ, Ruile P
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1082-1089 | PMID: 32588038
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Impact:
Abstract

Multimodality imaging derived energy loss index and outcome after transcatheter aortic valve replacement.

Holy EW, Nguyen-Kim TDL, Hoffelner L, Stocker D, ... Nietlispach F, Tanner FC
Aims 
To assess whether the combination of transthoracic echocardiography (TTE) and multidetector computed tomography (MDCT) data affects the grading of aortic stenosis (AS) severity under consideration of the energy loss index (ELI) in patients undergoing transcatheter aortic valve replacement (TAVR).
Methods and results 
Multimodality imaging was performed in 197 patients with symptomatic severe AS undergoing TAVR at the University Hospital Zurich, Switzerland. Fusion aortic valve area index (fusion AVAi) assessed by integrating MDCT derived planimetric left ventricular outflow tract area into the continuity equation was significantly larger as compared to conventional AVAi (0.41 ± 0.1 vs. 0.51 ± 0.1 cm2/m2; P < 0.01). A total of 62 patients (31.4%) were reclassified from severe to moderate AS with fusion AVAi being >0.6 cm2/m2. ELI was obtained for conventional AVAi and fusion AVAi based on sinotubular junction area determined by TTE (ELILTL 0.47 ± 0.1 cm2/m2; fusion ELILTL 0.60 ± 0.1 cm2/m2) and MDCT (ELIMDCT 0.48 ± 0.1 cm2/m2; fusion ELIMDCT 0.61 ± 0.05 cm2/m2). When ELI was calculated with fusion AVAi the effective orifice area was >0.6 cm2/m2 in 85 patients (43.1%). Survival rate 3 years after TAVR was higher in patients reclassified to moderate AS according to multimodality imaging derived ELI (78.8% vs. 67%; P = 0.01).
Conclusion 
Multimodality imaging derived ELI reclassifies AS severity in 43% undergoing TAVR and predicts mid-term outcome.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1092-1102
Holy EW, Nguyen-Kim TDL, Hoffelner L, Stocker D, ... Nietlispach F, Tanner FC
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1092-1102 | PMID: 32533142
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Impact:
Abstract

High-molecular-weight von Willebrand Factor multimer ratio differentiates true-severe from pseudo-severe classical low-flow, low-gradient aortic stenosis.

Kellermair J, Saeed S, Ott HW, Kammler J, ... Chambers JB, Steinwender C
Aims
Upon high wall shear stress, high-molecular-weight (HMW) von Willebrand Factor (VWF) multimers are degraded, thus, HMW VWF multimer deficiency mirrors haemodynamics at the site of aortic stenosis (AS). The aim of the present study was to analyse the role of HMW VWF multimer ratio for subcategorization of classical low-flow, low-gradient (LF/LG) AS.
Methods and results
Eighty-three patients with classical LF/LG AS were prospectively recruited and HMW VWF multimer pattern was analysed using a densitometric quantification of western blot bands. Patients were subclassified into true-severe (TS) and pseudo-severe (PS) classical LF/LG AS based on dobutamine stress echocardiography (DSE). Positive and negative predictive values (PPV/NPV) of HMW VWF multimer ratio for diagnosis of the TS subtype were calculated. HMW VWF multimer ratio in TS classical LF/LG AS was significantly decreased compared to PS classical LF/LG AS (0.86 ± 0.27 vs. 1.06 ± 0.09, P < 0.001). HMW VWF multimer deficiency occurred exclusively in the TS subtype with an optimal PPV of 1.000 and NPV of 0.379. HMW VWF multimer ratio showed a strong correlation with mean transvalvular pressure gradients during DSE (r = -0.616; P < 0.001). HMW VWF multimer ratio measured at baseline was higher compared to levels measured after DSE (0.87 ± 0.27 vs. 0.84 ± 0.31; P = 0.031) indicating DSE-induced increased proteolysis.
Conclusion
HMW VWF multimer ratio represents a valuable biomarker for classical LF/LG AS subclassification and mirrors haemodynamics during DSE. HMW VWF multimer ratio identifies the TS subtype without the use of other imaging techniques.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1123-1130
Kellermair J, Saeed S, Ott HW, Kammler J, ... Chambers JB, Steinwender C
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1123-1130 | PMID: 32417907
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Impact:
Abstract

Subclinical leaflet thrombosis is associated with impaired reverse remodelling after transcatheter aortic valve implantation.

Szilveszter B, Oren D, Molnár L, Apor A, ... Maurovich-Horvat P, Merkely B
Aims
Cardiac CT is increasingly applied for planning and follow-up of transcatheter aortic valve implantation (TAVI). However, there are no data available on reverse remodelling after TAVI assessed by CT. Therefore, we aimed to evaluate the predictors and the prognostic value of left ventricular (LV) reverse remodelling following TAVI using CT angiography.
Methods and results
We investigated 117 patients with severe, symptomatic aortic stenosis (AS) who underwent CT scanning before and after TAVI procedure with a mean follow-up time of 2.6 years after TAVI. We found a significant reduction in LV mass (LVM) and LVM indexed to body surface area comparing pre- vs. post-TAVI images: 180.5 ± 53.0 vs. 137.1 ± 44.8 g and 99.7 ± 25.4 vs. 75.4 ± 19.9 g/m2, respectively, both P < 0.001. Subclinical leaflet thrombosis (SLT) was detected in 25.6% (30/117) patients. More than 20% reduction in LVM was defined as reverse remodelling and was detected in 62.4% (73/117) of the patients. SLT, change in mean pressure gradient on echocardiography and prior myocardial infarction was independently associated with LV reverse remodelling after adjusting for age, gender, and traditional risk factors (hypertension, body mass index, diabetes mellitus, and hyperlipidaemia): OR = 0.27, P = 0.022 for SLT and OR = 0.22, P = 0.006 for prior myocardial infarction, OR = 1.51, P = 0.004 for 10 mmHg change in mean pressure gradient. Reverse remodelling was independently associated with favourable outcomes (HR = 0.23; P = 0.019).
Conclusion
TAVI resulted in a significant LVM regression on CT. The presence of SLT showed an inverse association with LV reverse remodelling and thus it may hinder the beneficial LV structural changes. Reverse remodelling was associated with improved long-term prognosis.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1144-1151
Szilveszter B, Oren D, Molnár L, Apor A, ... Maurovich-Horvat P, Merkely B
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1144-1151 | PMID: 31665257
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Abstract

Valvular calcification and risk of peripheral artery disease: the Multi-Ethnic Study of Atherosclerosis (MESA).

Garg PK, Buzkova P, Meyghani Z, Budoff MJ, ... Cushman M, Allison M
Aims
The detection of cardiac valvular calcification on routine imaging may provide an opportunity to identify individuals at increased risk for peripheral artery disease (PAD). We investigated the associations of aortic valvular calcification (AVC) and mitral annular calcification (MAC) with risk of developing clinical PAD or a low ankle-brachial index (ABI).
Methods and results
AVC and MAC were measured on cardiac computed tomography in 6778 Multi-Ethnic Study of Atherosclerosis participants without baseline PAD between 2000 and 2002. Clinical PAD was ascertained through 2015. Incident low ABI, defined as ABI <0.9 and decline of ≥0.15, was assessed among 5762 individuals who had an ABI >0.9 at baseline and at least one follow-up ABI measurement 3-10 years later. Adjusted Cox proportional hazards and Poisson regression modelling were used to determine the association of valvular calcification with clinical PAD and low ABI, respectively. There were 117 clinical PAD and 198 low ABI events that occurred over a median follow-up of 14 years and 9.2 years, respectively. The presence of MAC was associated with an increased risk of clinical PAD [hazard ratio 1.79; 95% confidence interval (CI) 1.04-3.05] but not a low ABI (rate ratio 1.28; 95% CI 0.75-2.19). No significant associations were noted for the presence of AVC and risk of either clinical PAD.
Conclusion
MAC is associated with an increased risk of developing clinical PAD. Future studies are needed to corroborate our findings and better understand whether MAC holds any predictive value as a risk marker for PAD.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1152-1159
Garg PK, Buzkova P, Meyghani Z, Budoff MJ, ... Cushman M, Allison M
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1152-1159 | PMID: 31740939
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Abstract

Tricuspid valve geometry and right heart remodelling: insights into the mechanism of atrial functional tricuspid regurgitation.

Utsunomiya H, Harada Y, Susawa H, Ueda Y, ... Nakano Y, Kihara Y
Aims 
We sought to investigate tricuspid valve (TV) geometry and right heart remodelling in atrial functional tricuspid regurgitation (AF-TR) as compared with ventricular functional TR with sinus rhythm (VF-TR).
Methods and results 
Transoesophageal 3D echocardiography datasets of the TV and right ventricle were acquired in 51 symptomatic patients with severe TR (AF-TR, n = 23; VF-TR, n = 28). Three-dimensional right ventricular (RV) endocardial surfaces were reconstructed throughout the cardiac cycle and then postprocessed using semiautomated integration and segmentation software to calculate position of papillary muscle (PM) tips. Compared with VF-TR, AF-TR had more dilated and posteriorly displaced annulus and less leaflet tethering angles with more prominent right atrium and smaller RV end-systolic volume. On the XY (annular) plane, the centre of annulus was getting closer towards the anterior and posterior PM tips and was going away from the medial PM tip caused by prominent annular dilatation in AF-TR. On the Z-axis, the position of each PM tip in AF-TR was not so much displaced apically as that in VF-TR. Multiple linear regression analyses revealed that right atrial volume and right atrial/RV end-systolic volume ratio were determinants of annular area and orientation in AF-TR, respectively (both P < 0.001). Additionally, the posteromedial-directed component of posterior PM tip position and the apically directed component of the position of all three PM tips were independently associated with TV tethering angles of each leaflet in AF-TR (all P < 0.02).
Conclusion 
Right heart remodelling and its association with 3D TV geometry differ entirely between AF-TR and VF-TR, which may offer distinctive therapeutic implication.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1068-1078
Utsunomiya H, Harada Y, Susawa H, Ueda Y, ... Nakano Y, Kihara Y
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1068-1078 | PMID: 32756989
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Impact:
Abstract

Left Atrial Strain as a Predictor of New-Onset Atrial Fibrillation in Patients With Heart Failure.

Park JJ, Park JH, Hwang IC, Park JB, Cho GY, Marwick TH
Objectives
This study sought to identify whether left atrial strain can predict new-onset atrial fibrillation (NOAF) in patients with heart failure (HF) and sinus rhythm.
Background
Both HF and atrial fibrillation have common risk factors, and HF is a risk factor for the development of atrial fibrillation and vice versa.
Methods
Among 4,312 consecutive patients with acute HF from 3 tertiary hospitals, 2,461 patients with sinus rhythm and peak atrial longitudinal strain (PALS) were included in the study. Reduced PALS was defined as PALS ≤18%, and the primary endpoint was 5-year NOAF.
Results
During a 5-year follow-up, 397 (16.1%) patients developed NOAF. Patients with reduced PALS had higher NOAF than their counterparts (18.2% vs. 12.7%; p < 0.001). After adjustment for significant covariates, we identified 6 independent predictors of NOAF, including age >70 years (hazard ratio [HR]: 1.50; 95% confidence interval [CI]: 1.12 to 2.00), hypertension (HR: 1.45; 95% CI: 1.10 to 1.91), left atrial volume index ≥40 ml/m (HR: 2.03; 95% CI: 1.48 to 2.77), PALS <18% (HR: 1.60; 95% CI: 1.18 to 2.17), HF with preserved ejection fraction (HR: 1.47; 95% CI: 1.11 to 1.95), and no beta-blocker prescription at discharge (HR: 1.48; 95% CI: 1.14 to 1.92). A weighted score based on these variables was used to create a composite score, HAS-BAP (H = hypertension; A = age; S = PALS; B = no beta-blocker prescription at discharge; A = atrial volume index; P = HF with preserved ejection fraction [range 0 to 6] with a median of 3 [interquartile range: 2 to 4]). The probability of NOAF increased with HAS-BAP score.
Conclusions
In patients with HF and sinus rhythm, 16.1% developed NOAF, and PALS could be used to predict the risk for NOAF. The HAS-BAP score allows determination of the risk of NOAF. (Strain for Risk Assessment and Therapeutic Strategies in Patients With Acute Heart Failure [STRATS-AHF] Registry; NCT03513653).

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

JACC Cardiovasc Imaging: 29 Sep 2020; 13:2071-2081
Park JJ, Park JH, Hwang IC, Park JB, Cho GY, Marwick TH
JACC Cardiovasc Imaging: 29 Sep 2020; 13:2071-2081 | PMID: 32682715
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Impact:
Abstract

A Clinical Tool to Identify Candidates for Stress-First Myocardial Perfusion Imaging.

Rouhani S, Al Shahrani A, Hossain A, Yam Y, ... Dorbala S, Chow BJW
Objectives
This study sought to develop a clinical model that identifies a lower-risk population for coronary artery disease that could benefit from stress-first myocardial perfusion imaging (MPI) protocols and that can be used at point of care to risk stratify patients.
Background
There is an increasing interest in stress-first and stress-only imaging to reduce patient radiation exposure and improve patient workflow and experience.
Methods
A secondary analysis was conducted on a single-center cohort of patients undergoing single-photon emission computed tomography (SPECT) and positron emission tomography (PET) studies. Normal MPI was defined by the absence of perfusion abnormalities and other ischemic markers and the presence of normal left ventricular wall motion and left ventricular ejection fraction. A model was derived using a cohort of 18,389 consecutive patients who underwent SPECT and was validated in a separate cohort of patients who underwent SPECT (n = 5,819), 1 internal cohort of patients who underwent PET (n=4,631), and 1 external PET cohort (n = 7,028).
Results
Final models were made for men and women and consisted of 9 variables including age, smoking, hypertension, diabetes, dyslipidemia, typical angina, prior percutaneous coronary intervention, prior coronary artery bypass graft, and prior myocardial infarction. Patients with a score ≤1 were stratified as low risk. The model was robust with areas under the curve of 0.684 (95% confidence interval [CI]: 0.674 to 0.694) and 0.681 (95% CI: 0.666 to 0.696) in the derivation cohort, 0.745 (95% CI: 0.728 to 0.762) and 0.701 (95% CI: 0.673 to 0.728) in the SPECT validation cohort, 0.672 (95% CI: 0.649 to 0.696) and 0.686 (95% CI: 0.663 to 0.710) in the internal PET validation cohort, and 0.756 (95% CI: 0.740 to 0.772) and 0.737 (95% CI: 0.716 to 0.757) in the external PET validation cohort in men and women, respectively. Men and women who scored ≤1 had negative likelihood ratios of 0.48 and 0.52, respectively.
Conclusions
A novel model, based on easily obtained clinical variables, is proposed to identify patients with low probability of having abnormal MPI results. This point-of-care tool may be used to identify a population that might qualify for stress-first MPI protocols.

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

JACC Cardiovasc Imaging: 29 Sep 2020; 13:2193-2202
Rouhani S, Al Shahrani A, Hossain A, Yam Y, ... Dorbala S, Chow BJW
JACC Cardiovasc Imaging: 29 Sep 2020; 13:2193-2202 | PMID: 32563652
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Impact:
Abstract

Shear Stress Estimated by Quantitative Coronary Angiography Predicts Plaques Prone to Progress and Cause Events.

Bourantas CV, Zanchin T, Torii R, Serruys PW, ... Raber L, Stone GW
Objectives
This study examined the value of endothelial shear stress (ESS) estimated in 3-dimensional quantitative coronary angiography (3D-QCA) models in detecting plaques that are likely to progress and cause events.
Background
Cumulative evidence has shown that plaque characteristics and ESS derived from intravascular ultrasound (IVUS)-based reconstructions enable prediction of lesions that will cause cardiovascular events. However, the prognostic value of ESS estimated by 3D-QCA in nonflow limiting lesions is yet unclear.
Methods
This study analyzed baseline virtual histology (VH)-IVUS and angiographic data from 28 lipid-rich lesions (i.e., fibroatheromas) that caused major adverse cardiovascular events or required revascularization (MACE-R) at 5-year follow-up and 119 lipid-rich plaques from a control group that remained quiescent. The segments studied by VH-IVUS at baseline were reconstructed using 3D-QCA software. In the obtained geometries, blood flow simulation was performed, and the pressure gradient across the lipid-rich plaque and the mean ESS values in 3-mm segments were estimated. The additive value of these hemodynamic indexes in predicting MACE-R beyond plaque characteristics was examined.
Results
MACE-R lesions were longer, had smaller minimum lumen area, increased plaque burden (PB), were exposed to higher ESS, and exhibited a higher pressure gradient. In multivariable analysis, PB (hazard ratio: 1.08; p = 0.004) and the maximum 3-mm ESS value (hazard ratio: 1.11; p = 0.001) were independent predictors of MACE-R. Lesions exposed to high ESS (>4.95 Pa) with a high-risk anatomy (minimal lumen area <4 mm and PB >70%) had a higher MACE-R rate (53.8%) than those with a low-risk anatomy exposed to high ESS (31.6%) or those exposed to low ESS who had high- (20.0%) or low-risk anatomy (7.1%; p < 0.001).
Conclusions
In the present study, 3D-QCA-derived local hemodynamic variables provided useful prognostic information, and, in combination with lesion anatomy, enabled more accurate identification of MACE-R lesions.

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

JACC Cardiovasc Imaging: 29 Sep 2020; 13:2206-2219
Bourantas CV, Zanchin T, Torii R, Serruys PW, ... Raber L, Stone GW
JACC Cardiovasc Imaging: 29 Sep 2020; 13:2206-2219 | PMID: 32417338
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Impact:
Abstract

Conceiving MitraClip as a tool: percutaneous edge-to-edge repair in complex mitral valve anatomies.

Gavazzoni M, Taramasso M, Zuber M, Russo G, ... Miura M, Maisano F

Improvements in procedural technique and intra-procedural imaging have progressively expanded the indications of percutaneous edge-to-edge technique. To date in higher volume centres and by experienced operators MitraClip is used for the treatment of complex anatomies and challenging cases in high risk-inoperable patients. This progressive step is superimposable to what observed in surgery for edge-to-edge surgery (Alfieri\'s technique). Moreover, the results of clinical studies on the treatment of patients with high surgical risk and functional mitral insufficiency have confirmed that the main goal to be achieved for improving clinical outcomes of patients with severe mitral regurgitation (MR) is the reduction of MR itself. The MitraClip should therefore be considered as a tool to achieve this goal in addition to medical therapy. Nowadays, evaluation of patient\'s candidacy to MitraClip procedure, discussed in local Heart Team, must take into account not only the clinical features of patients but even the experience of the operators and the volume of the centre, which are mostly related to the probability to achieve good procedural results. This \'relative feasibility\' of challenges cases by experienced operators should always been taken into account in selecting patients for MitraClip. Here, we present a review of the literature available on the treatment of complex and challenging lesions.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1059-1067
Gavazzoni M, Taramasso M, Zuber M, Russo G, ... Miura M, Maisano F
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1059-1067 | PMID: 32408344
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Impact:
Abstract

The fallacy of indexed effective orifice area charts to predict prosthesis-patient mismatch after prosthesis implantation.

Vriesendorp MD, Van Wijngaarden RAFL, Head SJ, Kappetein AP, ... Sabik JF, Klautz RJM
Aims 
Indexed effective orifice area (EOAi) charts are used to determine the likelihood of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR). The aim of this study is to validate whether these EOAi charts, based on echocardiographic normal reference values, can accurately predict PPM.
Methods and results 
In the PERIcardial SurGical AOrtic Valve ReplacemeNt (PERIGON) Pivotal Trial, 986 patients with aortic valve stenosis/regurgitation underwent AVR with an Avalus valve. Patients were randomly split (50:50) into training and test sets. The mean measured EOAs for each valve size from the training set were used to create an Avalus EOAi chart. This chart was subsequently used to predict PPM in the test set and measures of diagnostic accuracy (sensitivity, specificity, and negative and positive predictive value) were assessed. PPM was defined by an EOAi ≤0.85 cm2/m2, and severe PPM was defined as EOAi ≤0.65 cm2/m2. The reference values obtained from the training set ranged from 1.27 cm2 for size 19 mm up to 1.81 cm2 for size 27 mm. The test set had an incidence of 66% of PPM and 24% of severe PPM. The EOAi chart inaccurately predicted PPM in 30% of patients and severe PPM in 22% of patients. For the prediction of PPM, the sensitivity was 87% and the specificity 37%. For the prediction of severe PPM, the sensitivity was 13% and the specificity 98%.
Conclusion 
The use of echocardiographic normal reference values for EOAi charts to predict PPM is unreliable due to the large proportion of misclassifications.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1116-1122
Vriesendorp MD, Van Wijngaarden RAFL, Head SJ, Kappetein AP, ... Sabik JF, Klautz RJM
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1116-1122 | PMID: 32243493
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Impact:
Abstract

Mechanisms of mitral regurgitation after percutaneous mitral valve repair with the MitraClip.

Ikenaga H, Makar M, Rader F, Siegel RJ, ... Makkar RR, Shiota T
Aims
We sought to find the morphological mechanisms of recurrent mitral regurgitation (MR) after MitraClip procedure using 3D transoesophageal echocardiography (TOE).
Methods and results
Of 478 consecutive patients treated with the initial MitraClip procedure, 41 patients who underwent repeat mitral valve (MV) transcatheter or surgical intervention for recurrent MR were retrospectively reviewed. Using 3D-TOE, we investigated morphological changes of MV leading to repeat MV intervention. Aetiology of MR at the index intervention was primary in 24 (59%) and secondary in 17 (41%) patients. In the primary MR group, worsening leaflet prolapse at the clip site caused recurrent MR in 12 (50%) patients, while 7 (29%) patients had a leaflet tear at the clip site. Acute single leaflet device detachment was seen in four patients and one patient had recurrent MR between the plug and the clip. In secondary MR, left ventricular (LV)/left atrial dilation caused recurrent MR in 13 (76%) patients. Significant increase in the LV end-diastolic volume and tenting height were observed from post-index procedure to repeat intervention (LV end-diastolic volume; from 205 to 237 ml, P < 0.001, tenting height; from 0.8 to 1.3 cm, P < 0.001). New emergent leaflet prolapse/flail was seen in 3 (18%) patients, suggesting iatrogenic MR.
Conclusion
Mechanisms of recurrent MR after MitraClip procedure varied and depended on the underlying MV pathology: in primary MR, worsening mitral leaflet prolapse and in secondary MR, progressive LV dilation with worsening tenting were the main causes of recurrent MR.

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

Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1131-1143
Ikenaga H, Makar M, Rader F, Siegel RJ, ... Makkar RR, Shiota T
Eur Heart J Cardiovasc Imaging: 30 Sep 2020; 21:1131-1143 | PMID: 31605479
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Impact:
Abstract

Association Between Left Ventricular Mechanical Deformation and Myocardial Fibrosis in Nonischemic Cardiomyopathy.

Csecs I, Pashakhanloo F, Paskavitz A, Jang J, ... Manning WJ, Nezafat R

Background In patients with nonischemic cardiomyopathy, nonischemic fibrosis detected by late gadolinium enhancement (LGE) cardiovascular magnetic resonance is related to adverse cardiovascular outcomes. However, its relationship with left ventricular (LV) mechanical deformation parameters remains unclear. We sought to investigate the association between LV mechanics and the presence, location, and extent of fibrosis in patients with nonischemic cardiomyopathy. Methods and Results We retrospectively identified 239 patients with nonischemic cardiomyopathy (67% male; 55±14 years) referred for a clinical cardiovascular magnetic resonance. LGE was present in 109 patients (46%), most commonly (n=52; 22%) in the septum. LV deformation parameters did not differentiate between LGE-positive and LGE-negative groups. Global longitudinal, radial, and circumferential strains, twist and torsion showed no association with extent of fibrosis. Patients with septal fibrosis had a more depressed LV ejection fraction (30±12% versus 35±14%; =0.032) and more impaired global circumferential strain (-7.9±3.5% versus -9.7±4.4%; =0.045) and global radial strain (10.7±5.2% versus 13.3±7.7%; =0.023) than patients without septal LGE. Global longitudinal strain was similar in both groups. While patients with septal-only LGE (n=28) and free wall-only LGE (n=32) had similar fibrosis burden, the septal-only LGE group had more impaired LV ejection fraction and global circumferential, longitudinal, and radial strains (all <0.05). Conclusions There is no association between LV mechanical deformation parameters and presence or extent of fibrosis in patients with nonischemic cardiomyopathy. Septal LGE was associated with poor global LV function, more impaired global circumferential and radial strains, and more impaired global strain rates.



J Am Heart Assoc: 01 Oct 2020:e016797; epub ahead of print
Csecs I, Pashakhanloo F, Paskavitz A, Jang J, ... Manning WJ, Nezafat R
J Am Heart Assoc: 01 Oct 2020:e016797; epub ahead of print | PMID: 33006296
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Abstract

On the optimal temporal resolution for phase contrast cardiovascular magnetic resonance imaging: establishment of baseline values.

Santini F, Pansini M, Hrabak-Paar M, Yates D, ... Bieri O, Schubert T
Background
The aim of this study is to quantify the frequency content of the blood velocity waveform in different body regions by means of phase contrast (PC) cardiovascular magnetic resonance (CMR) and Doppler ultrasound. The highest frequency component of the spectrum is inversely proportional to the ideal temporal resolution to be used for the acquisition of flow-sensitive imaging (Shannon-Nyquist theorem).
Methods
Ten healthy subjects (median age 33y, range 24-40) were scanned with a high-temporal-resolution PC-CMR and with Doppler ultrasound on three body regions (carotid arteries, aorta and femoral arteries). Furthermore, 111 patients (median age 61y) with mild to moderate arterial hypertension and 58 patients with aortic aregurgitation, atrial septal defect, or repaired tetralogy of Fallot underwent aortic CMR scanning. The frequency power distribution was calculated for each location and the maximum frequency component, f, was extracted and expected limits for the general population were inferred.
Results
In the healthy subject cohort, significantly different f values were found across the different body locations, but they were nonsignificant across modalities. No significant correlation was found with heart rate. The measured f ranged from 7.7 ± 1.1 Hz in the ascending aorta, up to 12.3 ± 5.1 Hz in the femoral artery (considering PC-CMR data). The calculated upper boundary for the general population ranged from 11.0 Hz to 27.5 Hz, corresponding to optimal temporal resolutions of 45 ms and 18 ms, respectively. The patient cohort exhibited similar values for the frequencies in the aorta, with no correlation between blood pressure and frequency content.
Conclusions
The temporal resolution of PC-CMR acquisitions can be adapted based on the scanned body region and in the adult population, should approach approximately 20 ms in the peripheral arteries and 40 ms in the aorta.
Trial registration
This study presents results from a restrospective analysis of the clinical study NCT01870739 (ClinicalTrials.gov).



J Cardiovasc Magn Reson: 04 Oct 2020; 22:72
Santini F, Pansini M, Hrabak-Paar M, Yates D, ... Bieri O, Schubert T
J Cardiovasc Magn Reson: 04 Oct 2020; 22:72 | PMID: 33012283
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Abstract

Predictors of left ventricular reverse remodelling after coarctation of aorta intervention.

Egbe AC, Miranda WR, Connolly HM
Aims
Several coarctation of aorta (COA) severity indices are used for timing of COA intervention, and to define severity of residual coarctation post-intervention. However, it is unclear how many of these COA indices are required in order to recommend intervention, and what degree of residual coarctation results in suboptimal recovery of the left ventricle (LV). Our aim was to assess the correlation between different COA indices and effects of chronic LV pressure overload (LV hypertrophy, diastolic, and systolic dysfunction), and to determine the effect of residual coarctation on LV reverse remodelling after COA intervention.
Methods and results
COA severity indices were defined as Doppler COA gradient, systolic blood pressure (SBP, upper-to-lower-extremity SBP gradient, aortic isthmus ratio. LV remodelling indices were defined as LV mass index (LVMI), LV global longitudinal strain (LVGLS), e\' and E/e\'. LV reverse remodelling was defined as the difference between indices obtained pre-intervention and 5-year post-intervention (delta LVMI, e\', E/e\', LVGLS).Of the COA indices analysed in 546 adult COA patients, aortic isthmus ratio had the strongest correlation with LVMI (β ± standard error -28.3 ± 14.1, P < 0.001), LVGLS (1.51 ± 0.42, P = 0.005), e\' (3.11 ± 1.10, P = 0.014), and E/e\' (-13.4 ± 6.67, P = 0.008). Residual aortic isthmus ratio also had the strongest correlation with LV reverse remodelling, and residual aortic isthmus ratio <0.7 was predictive of suboptimal LV reverse remodelling post-intervention.
Conclusion
Considering the known prognostic implications of LV remodelling and reverse remodelling in response to pressure overload, these results support the use of aortic isthmus ratio for timing of COA intervention, and for prognostication post-intervention.

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

Eur Heart J Cardiovasc Imaging: 05 Oct 2020; epub ahead of print
Egbe AC, Miranda WR, Connolly HM
Eur Heart J Cardiovasc Imaging: 05 Oct 2020; epub ahead of print | PMID: 33020809
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Abstract

Left ventricular thrombus on cardiovascular magnetic resonance imaging in non-ischaemic cardiomyopathy.

Hooks M, Okasha O, Velangi PS, Nijjar PS, Farzaneh-Far A, Shenoy C
Aims
Case reports have described left ventricular (LV) thrombus in patients with non-ischaemic cardiomyopathy (NICM). We aimed to systematically study the characteristics, predictors, and outcomes of LV thrombus in NICM.
Methods and results
Forty-eight patients with LV thrombus detected on late gadolinium enhancement cardiovascular magnetic resonance imaging (LGE CMR) in NICM were compared with 124 patients with LV thrombus in ischaemic cardiomyopathy (ICM), and 144 matched patients with no LV thrombus in NICM. The performance of echocardiography for the detection of LV thrombus was compared between NICM and ICM. The 12-month incidence of embolism was compared between the three study groups. Independent predictors of LV thrombus in NICM were LV ejection fraction (LVEF) [hazard ratio (HR) 1.36 per 5% decrease; P = 0.002], LGE presence (HR 6.30; P < 0.001), and LGE extent (HR 1.33 per 5% increase; P = 0.001). Compared with patients with LV thrombus in ICM, those with LV thrombus in NICM had a 10-fold higher prevalence of thrombi in other cardiac chambers. The performance of echocardiography for the detection of LV thrombus was not different between NICM and ICM. The 12-month incidence of embolism associated with LV thrombus was not different between NICM and ICM (8.7% vs. 6.8%; P = 0.69) but both were higher compared with no LV thrombus in NICM (1.5%).
Conclusion
Independent predictors of LV thrombus in NICM were lower LVEF, LGE presence, and greater LGE extent. The 12-month incidence of embolism associated with LV thrombus in NICM was not different compared with LV thrombus in ICM.

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

Eur Heart J Cardiovasc Imaging: 06 Oct 2020; epub ahead of print
Hooks M, Okasha O, Velangi PS, Nijjar PS, Farzaneh-Far A, Shenoy C
Eur Heart J Cardiovasc Imaging: 06 Oct 2020; epub ahead of print | PMID: 33026088
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Abstract

Bicuspid aortic valve and aortopathy: novel prognostic predictors for the identification of high-risk patients.

Longobardo L, Carerj S, Bitto A, Cusmà-Piccione M, ... Khandheria BK, Zito C
Aims
Bicuspid aortic valve (BAV) may be complicated by aortic aneurysms and dissection. This study aimed to evaluate the prognostic efficacy of markers from cardiac imaging, as well as genetic and new biomarkers, to early predict aortic complications.
Methods and results
We re-evaluated after a mean time of 48 ± 11 months 47 BAV patients who had undergone previous echocardiography for evaluation of aortic stiffness and 2D aortic longitudinal strain (LS) (by speckle-tracking analysis), and who had given a blood sample for the assessment of a single-nucleotide polymorphism of elastin gene (ELN rs2 071307) and quantification of elastin soluble fragments (ESF). Surgical treatment of aortic aneurysm/dissection was the primary endpoint, and an aortic dimension increase (of one or more aortic segments) ≥1 mm/year was the secondary endpoint. Nine patients underwent surgical treatment of ascending aorta (AA) aneurysms. Out of the 38 patients who did not need surgical intervention, 16 showed an increase of aortic root and/or AA dimension ≥1 mm/year. At multivariate Cox regression analysis, an impaired AA LS was an independent predictor of aortic surgery [P = 0.04; hazard ratio (HR) 0.961; 95% confidence interval (CI) 0.924-0.984] and aortic dilatation (P = 0.007; HR 0.960; 95% CI 0.932-0.989). An increased quantity of ESF was correlated (P = 0.015) with the primary endpoint at univariate Cox regression analysis but it did not keep statistical significance at multivariate analysis.
Conclusion
In BAV patients, impairment of elastic properties of the AA, as assessed by 2D LS, is an effective predictor of aortic complications.

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

Eur Heart J Cardiovasc Imaging: 06 Oct 2020; epub ahead of print
Longobardo L, Carerj S, Bitto A, Cusmà-Piccione M, ... Khandheria BK, Zito C
Eur Heart J Cardiovasc Imaging: 06 Oct 2020; epub ahead of print | PMID: 33026072
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Abstract

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

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

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

Eur Heart J Cardiovasc Imaging: 06 Oct 2020; epub ahead of print
Lyhne MD, Kabrhel C, Giordano N, Andersen A, ... Zheng H, Dudzinski DM
Eur Heart J Cardiovasc Imaging: 06 Oct 2020; epub ahead of print | PMID: 33026070
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Abstract

Stress myocardial perfusion with qualitative magnetic resonance and quantitative dynamic computed tomography: comparison of diagnostic performance and incremental value over coronary computed tomography angiography.

de Knegt MC, Rossi A, Petersen SE, Wragg A, ... Jensen MT, Pugliese F
Aims
Assessment of haemodynamically significant coronary artery disease (CAD) using cardiovascular magnetic resonance (CMR) imaging perfusion or dynamic stress myocardial perfusion imaging by computed tomography (CT perfusion) may aid patient selection for invasive coronary angiography (ICA). We evaluated the diagnostic performance and incremental value of qualitative CMR perfusion and quantitative CT perfusion complementary to cardiac computed tomography angiography (CCTA) for the diagnosis of haemodynamically significant CAD using fractional flow reserve (FFR) and quantitative coronary angiography (QCA) as reference standard.
Methods and results
CCTA, qualitative visual CMR perfusion, visual CT perfusion, and quantitative relative myocardial blood flow (CT-MBF) were performed in patients with stable angina pectoris. FFR was measured in coronary vessels with stenosis visually estimated between 30% and 90% diameter reduction on ICA. Haemodynamically significant CAD was defined as FFR <0.80, or QCA ≥80% in those cases where FFR could not be performed. A total of 218 vessels from 93 patients were assessed. An optimal cut-off of 0.72 for relative CT-MBF was determined. The diagnostic performances (area under the receiver-operating characteristics curves, 95% CI) of visual CMR perfusion (0.84, 0.77-0.90) and relative CT-MBF (0.86, 0.81-0.92) were comparable and outperformed visual CT perfusion (0.64, 0.57-0.71). In combination with CCTA ≥50%, CCTA + visual CMR perfusion (0.91, 0.86-0.96), CCTA + relative CT-MBF (0.92, 0.88-0.96), and CCTA + visual CT perfusion (0.82, 0.75-0.90) improved discrimination compared with CCTA alone (all P < 0.05).
Conclusion
Visual CMR perfusion and relative CT-MBF outperformed visual CT perfusion and provided incremental discrimination compared with CCTA alone for the diagnosis of haemodynamically significant CAD.

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

Eur Heart J Cardiovasc Imaging: 07 Oct 2020; epub ahead of print
de Knegt MC, Rossi A, Petersen SE, Wragg A, ... Jensen MT, Pugliese F
Eur Heart J Cardiovasc Imaging: 07 Oct 2020; epub ahead of print | PMID: 33029616
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Abstract

Incremental prognostic value of coronary flow reserve determined by phase-contrast cine cardiovascular magnetic resonance of the coronary sinus in patients with diabetes mellitus.

Kato S, Fukui K, Kodama S, Azuma M, ... Tamura K, Utsunomiya D
Background
Although non-invasive assessment of coronary flow reserve (CFR) by cardiovascular magnetic resonance (CMR) provides prognostic information for patients with diabetes mellitus (DM), the incremental prognostic value of CMR-derived CFR remains unclear.
Purpose
To evaluate the incremental prognostic value of CMR-derived CFR for patients with DM who underwent stress CMR imaging.
Materials and methods
A total of 309 patients with type 2 DM [69 ± 9 years; 244 (78%) male] assessed between 2009 and 2019 were retrospectively reviewed. Coronary sinus blood flow (CSBF) was measured using phase contrast (PC) cine CMR. CFR was calculated as the CSBF during adenosine triphosphate infusion divided by that at rest. Major adverse cardiac events (MACE) were defined as death, acute coronary syndrome, hospitalization due to heart failure exacerbation, or sustained ventricular tachycardia. The incremental prognostic value of CFR over clinical and CMR variables was assessed by calculating the C-index and net reclassification improvement (NRI).
Results
During a median follow-up of 3.8 years, 42 patients (14%) experienced MACE. The annualized event rate was significantly higher among patients with CFR < 2.0, regardless of the presence of late gadolinium enhancement (LGE) (1.4% vs. 9.8%, p = 0.011 in the LGE (-) group; 1.8% vs. 16.9%, p < 0.001 in the LGE (+) group). In addition, this trend was maintained in the subgroups stratified by presence or absence of ischemia (0.3% vs. 6.7%, p = 0.007 in the ischemia (-) group; 3.9% vs. 17.1%, p = 0.001 in the ischemia (+) group). Adding CFR to the risk model (age + gender + left ventricular ejection fraction + %LGE + %ischemia) resulted in a significant increase of the C-index from 0.838 to 0.870 (p = 0.038) and an NRI of 0.201 (0.004-0.368, p = 0.012).
Conclusion
PC cine CMR-derived CFR of the coronary sinus may be useful as a prognostic marker for DM patients, incremental to common clinical and CMR parameters. Due to the high prevalence of coronary microvascular dysfunction, the addition of CFR to conventional vasodilator stress CMR imaging may improve risk stratification for patients with DM.



J Cardiovasc Magn Reson: 07 Oct 2020; 22:73
Kato S, Fukui K, Kodama S, Azuma M, ... Tamura K, Utsunomiya D
J Cardiovasc Magn Reson: 07 Oct 2020; 22:73 | PMID: 33028350
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Abstract

Evaluation of dyspnea of unknown etiology in HIV patients with cardiopulmonary exercise testing and cardiovascular magnetic resonance imaging.

Patterson AJ, Sarode A, Al-Kindi S, Shaver L, ... Simonetti O, Rajagopalan S
Aim
Human Immunodeficiency Virus (HIV) patients commonly experience dyspnea for which an immediate cause may not be always apparent. In this prospective cohort study of HIV patients with exercise limitation, we use cardiopulmonary exercise testing (CPET) coupled with exercise cardiovascular magnetic resonance (CMR) to elucidate etiologies of dyspnea.
Methods and results
Thirty-four HIV patients on antiretroviral therapy with dyspnea and exercise limitation (49.7 years, 65% male, mean absolute CD4 count 700) underwent comprehensive evaluation with combined rest and maximal exercise treadmill CMR and CPET. The overall mean oxygen consumption (VO) peak was reduced at 23.2 ± 6.9 ml/kg/min with 20 patients (58.8% of overall cohort) achieving a respiratory exchange ratio > 1. The ventilatory efficiency (VE)/VCO slope was elevated at 36 ± 7.92, while ventilatory reserve (VE: maximal voluntary ventilation (MVV)) was within normal limits. The mean absolute right ventricular (RV) and left ventricular (LV) contractile reserves were preserved at 9.0% ± 11.2 and 9.4% ± 9.4, respectively. The average resting and post-exercise mean average pulmonary artery velocities were 12.2 ± 3.9 cm/s and 18.9 ± 8.3 respectively, which suggested lack of exercise induced pulmonary artery hypertension (PAH). LV but not RV delayed enhancement were identified in five patients. Correlation analysis found no relationship between peak VO measures of contractile RV or LV reserve, but LV and RV stroke volume correlated with PET CO (p = 0.02, p = 0.03).
Conclusion
Well treated patients with HIV appear to have conserved RV and LV function, contractile reserve and no evidence of exercise induced PAH. However, we found evidence of impaired ventilation suggesting a non-cardiopulmonary etiology for dyspnea.



J Cardiovasc Magn Reson: 11 Oct 2020; 22:74
Patterson AJ, Sarode A, Al-Kindi S, Shaver L, ... Simonetti O, Rajagopalan S
J Cardiovasc Magn Reson: 11 Oct 2020; 22:74 | PMID: 33040733
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Abstract

Sudden Cardiac Death in Ischemic Heart Disease: From Imaging Arrhythmogenic Substrate to Guiding Therapies.

Gräni C, Benz DC, Gupta S, Windecker S, Kwong RY

Despite substantial medical advances over the past decades, sudden cardiac death (SCD) remains a leading cause of cardiovascular deaths in patients with ischemic heart disease. The presence of structural heart disease with left ventricular ejection fraction <35% is the current criteria for implantable cardioverter-defibrillator therapy as a primary prevention to SCD. However, more than 80% of patients who suffer SCD have a left ventricular ejection fraction >35%, whereas few patients who received an implantable cardioverter-defibrillator required appropriate defibrillation. Cardiac magnetic resonance enables the visualization of the arrhythmogenic myocardial substrate including the presence and pattern of scar and fibrosis. The most promising of these features, besides left ventricular function, strain analysis, and morphology, include tissue characterization using late-gadolinium enhancement, T1 mapping, and extracellular volume fraction calculation. We review the current evidence of SCD relating to ischemic heart disease, provide insights into imaging of the arrhythmogenic substrate that produces lethal ventricular arrhythmia, and discuss how imaging may guide therapies toward SCD prevention.

Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

JACC Cardiovasc Imaging: 29 Sep 2020; 13:2223-2238
Gräni C, Benz DC, Gupta S, Windecker S, Kwong RY
JACC Cardiovasc Imaging: 29 Sep 2020; 13:2223-2238 | PMID: 31864982
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This program is still in alpha version.