<div><h4>Transcatheter Aortic Valve Replacement Outcomes in Patients with Low-flow Very Low-gradient Aortic Stenosis.</h4><i>Ueyama H, Chopra L, Dalsania A, Prandi FR, ... Kini A, Lerakis S</i><br /><b>Aims</b><br />In patients with severe aortic stenosis (AS), low-flow, low-gradient (LG) is a known predictor of worse outcomes. However, very LG may represent a distinct population with further cardiac dysfunction. It is unknown whether this population benefits from transcatheter aortic valve replacement (TAVR). We aimed to describe the patient characteristics and clinical outcomes of low-flow very LG severe AS.<br /><b>Methods and results</b><br />This single-center study included all patients with low-flow severe AS between 2019 to 2021. Patients were divided into groups with very LG (mean pressure gradient [MPG] ≤ 20 mmHg), LG (20 < MPG < 40 mmHg), and high-gradient (HG) (MPG ≥ 40 mmHg). Composite endpoint of all-cause mortality and heart failure rehospitalization were compared. A total of 662 patients (very LG 130[20%]; LG 339[51%]; HG 193[29%]) were included. Median follow-up was 12 months. Very LG cohort had a higher prevalence of comorbid conditions with lower left ventricular ejection fraction (45%vs.57%vs.60%; p < 0.001). There was a graded increase in the risk of composite endpoint in the lower MPG strata (p < 0.001). Among those who underwent TAVR, very LG was an independent predictor of the composite endpoint (adjusted HR 2.42 [1.29-4.55]). While LG and HG cohorts had decreased risk of composite endpoint after TAVR compared to conservative management, very LG was not associated with risk reduction (adjusted HR 0.69 [0.35-1.34]).<br /><b>Conclusion</b><br />Low-flow very LG severe AS represents a distinct population with significant comorbidities and worse outcomes. Further studies are needed to evaluate the short- and long-term benefits of TAVR in this population.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 29 Sep 2023; epub ahead of print</small></div>

<div><h4>Incremental prognostic value of downstream PET perfusion imaging after coronary CT angiography.</h4><i>Lehtonen E, Kujala I, Tamminen J, Maaniitty T, ... Knuuti J, Klén R</i><br /><b>Purpose</b><br />To evaluate the incremental value of positron emission tomography (PET) myocardial perfusion imaging (MPI) over coronary computed tomography angiography (CCTA) in predicting short- and long-term outcome using machine learning (ML) approaches.<br /><b>Methods</b><br />2411 patients with clinically suspected coronary artery disease (CAD) underwent CCTA, out of whom 891 patients were admitted to downstream PET MPI for hemodynamic evaluation of obstructive coronary stenosis. Two sets of Extreme Gradient Boosting (XGBoost) ML models were trained, one with all the clinical and imaging variables (including PET) and the other with only clinical and CCTA-based variables. Difference in the performance of the two sets was analyzed by means of area under the receiver operating characteristic curve (AUC).<br /><b>Results</b><br />After the removal of incomplete data entries, 2284 patients remained for further analysis. During 8-year follow-up, 210 adverse events occurred including 59 myocardial infarctions, 35 unstable angina pectoris, and 116 deaths. The PET MPI data improved the outcome prediction over CCTA during the first 4 years of observation time and the highest AUC was at the observation time of year 1 (0.82, 95% CI 0.804 - 0.827). After that, there was no significant incremental prognostic value by PET MPI.<br /><b>Conclusion</b><br />PET MPI variables improve the prediction of adverse events beyond CCTA imaging alone for the first 4 years of follow-up. This illustrates the complementary nature of anatomic and functional information in predicting outcome of patients with suspected CAD.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 29 Sep 2023; epub ahead of print</small></div>

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

<div><h4>Non-invasive estimation of left ventricular systolic peak-pressure - a prerequisite to calculate myocardial work in hypertrophic obstructive cardiomyopathy.</h4><i>Batzner A, Hahn P, Morbach C, Störk S, ... Frantz S, Seggewiss H</i><br /><b>Aims</b><br />Myocardial work (MyW) is an echocardiographically derived parameter to estimate myocardial performance. The calculation of MyW utilizes pressure strain loops from global longitudinal strain and brachial blood pressure (BP) as surrogate of left ventricular systolic pressure (LVSP). Since LVSP cannot be equated with BP in hypertrophic obstructive cardiomyopathy (HOCM), we explored whether LVSP can be derived non-invasively by combining Doppler gradients and BP.<br /><b>Methods and results</b><br />We studied 20 consecutive patients (8 women, 12 men; mean age 57.0 ± 13.9 years; NYHA 2.1 ± 0.8; maximal septal thickness 24.7 ± 6.3 mm) with indication for first alcohol septal ablation. All measurements were performed simultaneously in the catheterization laboratory (CathLab) - invasively: ascending aortic and LV pressures; non-invasively: BP, maximal (CWmax) and mean (CWmean) Doppler gradients.LVSP was 188.9 ± 38.5 mmHg. Mean gradients of both methods were comparable (CathLab 34.3 ± 13.4 mmHg vs. CW 31.0 ± 13.7 mmHg). Maximal gradient was higher in echocardiography (64.5 ± 28.8 mmHg) compared to CathLab (54.8 ± 24.0 mmHg; p < 0.05). Adding BP (143.1 ± 20.6 mmHg) to CWmax resulted in higher (207.7 ± 38.0 mmHg; p < 0.001), whereas adding BP to CWmean in lower (174.1 ± 26.1 mmHg; p < 0.01) derived LVSP compared to measured LVSP. However, adding BP to averaged CWmax and CWmean, resulted in comparable results for measured and derived LVSP (190.9 ± 31.6 mmHg) yielding a favourable correlation (r = 0.87, p < 0.001) and a good level of agreement in the Bland Altman plot.<br /><b>Conclusion</b><br />Non-invasive estimation of LVSP in HOCM is feasible by combining conventional BP and averaged CWmean and CWmax gradients. Hereby, a more reliable estimation of MyW in HOCM may be feasible.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 19 Sep 2023; epub ahead of print</small></div>

<div><h4>Noninvasive Assessment of Left Ventricular End-Diastolic Pressure Using Machine Learning Derived Phasic Left Atrial Strain.</h4><i>Gruca MM, Slivnick JA, Singh A, Cotella J, ... Su JL, Lang RM</i><br /><b>Background</b><br />While transthoracic echocardiography (TTE) assessment of left ventricular end-diastolic pressure (LVEDP) is critically important, the current paradigm is subject to error and indeterminate classification. Recently, peak left atrial strain (LAS) was found to be associated with LVEDP. We aimed to test the hypothesis that integration of the entire LAS time curve into a single parameter could improve the accuracy of peak LAS in the noninvasive assessment of LVEDP with TTE.<br /><b>Methods</b><br />We retrospectively identified 294 patients who underwent left heart catheterization and TTE within 24 hours. LAS curves were trained using machine learning (100 patients) to detect LVEDP>15mmHg, yielding the novel parameter LAS index (LASi). The accuracy of LASi was subsequently validated (194 patients), side-by-side with peak LAS and ASE/EACVI guidelines, against invasive filling pressures.<br /><b>Results</b><br />Within the validation cohort, invasive LVEDP was elevated in 116 (59.8%) patients. The overall accuracy of LASi, peak LAS and ASE/EACVI algorithm was 79%, 75%, and 76%, respectively (excluding 37 patients with indeterminate diastolic function by ASE/EACVI guidelines). When the number of LASi indeterminates (defined by near-zero LASi values) was matched to the ASE/EACVI guidelines (n=37), the accuracy of LASi improved to 87%. Importantly, among the 37 patients with ASE/EACVI-indeterminate diastolic function, LASi had an accuracy of 81%, compared to 76% for peak LAS.<br /><b>Conclusions</b><br />LASi allows the detection of elevated LVEDP using invasive measurements as a reference, at least as accurately as peak LAS and current diastolic function guidelines algorithm, with the advantage of no indeterminate classifications in patients with measurable LAS.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 14 Sep 2023; epub ahead of print</small></div>

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

<div><h4>Phenotyping left ventricular systolic dysfunction in asymptomatic individuals for improved risk stratification.</h4><i>Rauseo E, Abdulkareem M, Khan A, Cooper J, ... Slabaugh GG, Petersen SE</i><br /><b>Aims</b><br />Left ventricular systolic dysfunction (LSVD) is a heterogeneous condition with several factors influencing prognosis. Better phenotyping of asymptomatic individuals can inform preventative strategies. This study aims to explore the clinical phenotypes of LVSD in initially asymptomatic subjects and their association with clinical outcomes and cardiovascular abnormalities through multi-dimensional data clustering.<br /><b>Methods and results</b><br />Clustering analysis was performed on 60 clinically available variables from 1563 UK Biobank participants without pre-existing heart failure (HF) and with left ventricular ejection fraction (LVEF) < 50% on cardiovascular magnetic resonance (CMR) assessment. Risks of developing HF, other cardiovascular events, death, and a composite of major adverse cardiovascular events (MACE) associated with clusters were investigated. Cardiovascular imaging characteristics, not included in the clustering analysis, were also evaluated. Three distinct clusters were identified, differing considerably in lifestyle habits, cardiovascular risk factors, electrocardiographic parameters, and cardiometabolic profiles. A stepwise increase in risk profile was observed from Cluster 1 to Cluster 3, independent of traditional risk factors and LVEF. Compared with Cluster 1, the lowest risk subset, the risk of MACE ranged from 1.42 [95% confidence interval (CI): 1.03-1.96; P < 0.05] for Cluster 2 to 1.72 (95% CI: 1.36-2.35; P < 0.001) for Cluster 3. Cluster 3, the highest risk profile, had features of adverse cardiovascular imaging with the greatest LV re-modelling, myocardial dysfunction, and decrease in arterial compliance.<br /><b>Conclusions</b><br />Clustering of clinical variables identified three distinct risk profiles and clinical trajectories of LVSD amongst initially asymptomatic subjects. Improved characterization may facilitate tailored interventions based on the LVSD sub-type and improve clinical outcomes.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 12 Sep 2023; epub ahead of print</small></div>

<div><h4>Unraveling the Intricacies of Left Ventricular Hemodynamic Forces: Age and Gender-Specific Normative Values Assessed by Cardiac MRI in Healthy Adults.</h4><i>Yang W, Wang Y, Zhu L, Xu J, ... Zhao S, Lu M</i><br /><b>Aims</b><br />Hemodynamic forces(HDFs) provided a feasible method to early detect cardiac mechanical abnormalities by estimating the intraventricular pressure gradients. The novel advances in assessment of HDFs using routine cardiac magnetic resonance(CMR) cines shed new light on detection of preclinical dysfunction. However, definition of normal values for this new technique is the prerequisite for application in the clinic.<br /><b>Methods and results</b><br />A total of 218 healthy volunteers(38.1years ± 11.1; 111 male [50.9%]) were recruited and underwent CMR examinations with a 3.0 T scanner. Balanced steady state free precession breath hold cine images were acquired and HDF assessments were performed based on strain analysis. The normal values of longitudinal, transversal HDF strength(RMS) and ratio of transversal to longitudinal HDF were all evaluated in overall population as well as in both genders and in age-specific groups. The longitudinal RMS values(%) of HDFs were significantly higher in women (P < 0.05). Moreover, the HDF amplitudes significantly decreased with ageing in entire heartbeat, systole, diastole, systolic/diastolic transition and diastolic deceleration, while increased in atrial thrust. In multivariable linear regression analysis, age, heart rate and global longitudinal strain emerged as independent predictors of the amplitudes of longitudinal HDFs in entire heartbeat and systole, while left ventricular end-diastole volume index was also independently associated with longitudinal HDFs in diastole and diastolic deceleration(P < 0.05 for all).<br /><b>Conclusion</b><br />Our study provided comprehensive normal values of HDF assessments using CMR as well as presented with specific age and sex stratification. HDFs analyses can be performed with excellent intra and inter-observer reproducibility.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 19 Sep 2023; epub ahead of print</small></div>

<div><h4>Distal-Vessel Fractional Flow Reserve by Computed Tomography to Monitor Epicardial Coronary Artery Disease.</h4><i>Chen M, Almeida SO, Sayre JW, Karlsberg RP, Sevag Packard RR</i><br /><b>Aims</b><br />Coronary computed tomography angiography (CTA) and fractional flow reserve by computed tomography (FFR-CT) are increasingly utilized to characterize coronary artery disease (CAD). We evaluated the feasibility of distal-vessel FFR-CT as an integrated measure of epicardial CAD that can be followed serially, assessed the CTA parameters that correlate with distal-vessel FFR-CT, and determined the combination of clinical and CTA parameters that best predict distal-vessel FFR-CT and distal-vessel FFR-CT changes.<br /><b>Methods and results</b><br />Patients (n=71) who underwent serial CTA scans at ≥2 years interval (median=5.2 years) over a 14-year period were included in this retrospective study. Coronary arteries were analyzed blindly using artificial intelligence-enabled quantitative coronary CTA. Two investigators jointly determined the anatomic location and corresponding distal-vessel FFR-CT values at CT1 and CT2. 45.3% had no significant change, 27.8% an improvement, and 26.9% a worsening in distal-vessel FFR-CT at CT2. Stepwise multiple logistic regression analysis identified a four-parameter model consisting of stenosis diameter ratio, lumen volume, low density plaque volume, and age, that best predicted distal-vessel FFR-CT ≤0.80 with an area under the curve (AUC)=0.820 at CT1 and AUC=0.799 at CT2. Improvement of distal-vessel FFR-CT was captured by a decrease in high-risk plaque and increases in lumen volume and remodeling index (AUC=0.865), whereas increases in stenosis diameter ratio, medium density calcified plaque volume, and total cholesterol presaged worsening of distal-vessel FFR-CT (AUC=0.707).<br /><b>Conclusions</b><br />Distal-vessel FFR-CT permits the integrative assessment of epicardial atherosclerotic plaque burden in a vessel-specific manner and can be followed serially to determine changes in global CAD.<br /><br />Published by Oxford University Press on behalf of the European Society of Cardiology 2023.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 14 Sep 2023; epub ahead of print</small></div>

<div><h4>The year 2022 in the European Heart Journal - Cardiovascular Imaging: Part I.</h4><i>Petersen SE, Muraru D, Westwood M, Dweck MR, ... Delgado V, Cosyns B</i><br /><AbstractText>The European Heart Journal - Cardiovascular Imaging with its over ten years existence is an established leading multimodality cardiovascular imaging journal. Pertinent publications including original research, how to papers, reviews, consensus documents, in our Journal from 2022 have been highlighted in two reports. Part I focuses on cardiomyopathies, heart failure, valvular heart disease and congenital heart disease and related emerging techniques and technologies.</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 20 Sep 2023; epub ahead of print</small></div>

<div><h4>Non-invasive myocardial work in aortic stenosis - validation and improvement of left ventricular pressure estimation.</h4><i>Ribic D, Remme EW, Smiseth OA, Massey RJ, ... Broch K, Russell K</i><br /><b>Aims</b><br />The non-invasive myocardial work index (MWI) has been validated in patients without aortic stenosis (AS). A thorough assessment of methodological limitations is warranted before this index can be applied in patients with AS.<br /><b>Methods and results</b><br />We simultaneously measured left ventricular pressure (LVP) by a micromanometer-tipped catheter and obtained echocardiograms in 20 patients with severe AS. We estimated LVP curves and calculated pressure-strain loops using three different models: 1. The model validated in patients without AS; 2. The same model, but with pressure at aortic valve opening (AVO) adjusted to diastolic cuff pressure; and 3. A new model based on the invasive measurements from the AS patients. Valvular events were determined by echocardiography. Peak LVP was estimated as the sum of the mean aortic transvalvular gradient and systolic cuff pressure. In same-beat comparisons between invasive and estimated LVP curves, model 1 significantly overestimated early systolic pressure by 61 ± 5 mmHg at AVO compared to model 2 and 3. However, the average correlation coefficients between estimated and invasive LVP traces were excellent for all models and the overestimation had limited influence on MWI, with excellent correlation (r = 0.98, p < 0.001) and good agreement between the MWI calculated with estimated (all models) and invasive LVP.<br /><b>Conclusion</b><br />This study confirms the validity of the non-invasive MWI in patients with AS. The accuracy of estimated LVP curves improved when matching AVO to the diastolic pressure in the original model mirroring that of the AS-specific model. This may sequentially enhance accuracy of regional MVI assessment.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 06 Sep 2023; epub ahead of print</small></div>

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

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

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

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

<div><h4>Prevalence, mechanisms and prognostic impact of dynamic mitral regurgitation assessed by isometric handgrip exercise.</h4><i>Spieker M, Lagarden H, Sidabras J, Veulemans V, ... Kelm M, Westenfeld R</i><br /><b>Aims</b><br />The extent of mitral regurgitation (MR) may vary depending on the hemodynamic situation, thus, exercise testing plays an important role assessing the hemodynamic relevance of MR. We aim to assess prevalence, mechanisms and prognostic impact of exercise-induced changes in MR in patients with degenerative MR (DegMR) and functional MR (FMR).<br /><b>Methods and results</b><br />We enrolled 367 patients with at least mild MR that underwent standardized echocardiography at rest and during handgrip exercise. Handgrip exercise led to an increase in MR by one grade or more in 19% of DegMR, and 28% of FMR patients. In FMR, patients with exercise-induced increases in MR, handgrip exercise led to a reduction in left ventricular stroke volume index, being maintained in DegMR patients. Exercise-induced changes in systolic pulmonary artery pressure were linked to changes in effective regurgitant orifice area (DegMR: r=0.456; p<0.001; FMR: r=0.326; p<0.001). Thus, 26% of patients with DegMR and FMR developed pulmonary hypertension during exercise. In both cohorts, a significant proportion of patients with non-severe MR at rest and exercise-induced severe MR underwent mitral valve surgery/intervention during follow-up. In FMR patients (but not in DegMR patients), early mitral valve surgery/intervention was independently associated with lower event rates during follow-up (0.177 (0.027-0.643); p=0.025).<br /><b>Conclusions</b><br />Handgrip exercise echocardiography provides important information regarding the dynamic nature of MR, exercise-induced changes in left ventricular function and pulmonary circulation with subsequent consequences for further therapeutic decision making. Thus, it should be considered as a diagnostic tool in symptomatic patients with non-severe MR at rest.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 23 Sep 2023; epub ahead of print</small></div>

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

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

<div><h4>Pathophysiologic and Prognostic Importance of Cardiac Power Output Reserve in Heart Failure with Preserved Ejection Fraction.</h4><i>Takizawa D, Harada T, Obokata M, Kagami K, ... Wada N, Ishii H</i><br /><b>Aims</b><br />Heart failure with preserved ejection fraction (HFpEF) is a syndrome characterized by multiple cardiac reserve limitations during exercise. Cardiac power output (CPO) is an index of global cardiac performance and can be estimated noninvasively by echocardiography. We hypothesized that CPO reserve during exercise would be associated with impaired cardiovascular reserve, exercise intolerance, and adverse outcomes in HFpEF.<br /><b>Methods and results</b><br />Exercise stress echocardiography was performed in 425 dyspneic patients (217 HFpEF and 208 non-HF controls) to estimate CPO at rest and during exercise. We classified patients with HFpEF based on the median value of changes in CPO from rest to peak exercise (ΔCPO >0.49 W/100 g). Patients with HFpEF and lower CPO reserve had poorer biventricular systolic function and impaired chronotropic response during exercise and worse aerobic capacity than controls and those with higher CPO reserve. During a median follow-up of 358 days, a composite outcome of all-cause mortality or HF events occurred in 30 patients. Patients with lower CPO reserve had a four and nearly 10-fold increased risk of the outcomes compared to those with higher CPO reserve and controls, respectively (hazard ratio [HR] 4.05, 95% confidence interval [CI] 1.16-10.1, p = 0.003 and HR, 9.61 [95%CI, 3.58-25.8], p < 0.0001). We further found that lower CPO reserve had an incremental prognostic value over the H2FPEF score and exercise duration. In contrast, resting CPO did not predict clinical outcomes in patients with HFpEF.<br /><b>Conclusions</b><br />Lower CPO reserve was associated with biventricular systolic dysfunction, chronotropic incompetence, exercise intolerance, and adverse outcomes in patients with HFpEF.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 21 Sep 2023; epub ahead of print</small></div>

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

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

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

<div><h4>High-Definition Blood Flow Imaging Improves Quantification of LV volumes and Ejection Fraction.</h4><i>Gama F, Custódio P, Tsagkridi A, Moon J, ... Treibel TA, Bhattacharyya S</i><br /><b>Aims</b><br />The accuracy and reproducibility of echocardiography to quantify left ventricular ejection (LVEF) is limited due to image quality. High-definition blood flow imaging is a new technique which improves cavity delineation without the need for medication or intravenous access. We sought to examine the impact of high-definition blood flow imaging on accuracy and reproducibility of LV systolic function assessment.<br /><b>Methods & results</b><br />Prospective observational study of consecutive patients undergoing two dimensional (2D) and three dimensional (3D) echocardiography (TTE), high-definition blood flow imaging and cardiac magnetic resonance imaging (CMR) within 1 hour of each other. Left ventricular systolic function characterised by left ventricular systolic volumes (LVESV) and diastolic volumes (LVEDV) and LVEF were measured. Seventy-six patients were included. Correlation of 2D TTE with CMR was modest (r = 0.68) with a worse correlation in patients with 3 or more segments not visualised (r = 0.58). High-definition blood flow imaging was feasible in all patients and the correlation of LVEF with CMR was excellent (r = 0.88). The difference between 2D, High-Definition Blood Flow and 3D TTE compared to CMR were 5 ± 9%, 2 ± 5% and 1 ± 3% respectively. The proportion of patients where the grade of LV function was correctly classified improved from 72.3% using 2D TTE to 92.8% using high-definition blood flow imaging. 3D TTE also had excellent correlation with CMR (r = 0.97) however was only feasible in 72.4% of patients.<br /><b>Conclusion</b><br />High-definition blood flow imaging is highly feasible and significantly improves the diagnostic accuracy and grading of LV function compared to 2D echocardiography.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 27 Sep 2023; epub ahead of print</small></div>

<div><h4>Phenotyping heart failure by genetics and associated conditions.</h4><i>Wong J, Peters S, Marwick TH</i><br /><AbstractText>Heart failure is a highly heterogeneous disease, and genetic testing may allow phenotypic distinctions that are incremental to those obtainable from imaging. Advances in genetic testing have allowed for the identification of deleterious variants in patients with specific heart failure phenotypes (dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and hypertrophic cardiomyopathy), and many of these have specific treatment implications. The diagnostic yield of genetic testing in heart failure is modest, and many rare variants are associated with incomplete penetrance and variable expressivity. Environmental factors and co-morbidities have a large role in the heterogeneity of the heart failure phenotype. Future endeavours should concentrate on the cumulative impact of genetic polymorphisms in the development of heart failure.</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 26 Sep 2023; 24:1293-1301</small></div>

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

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

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

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

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