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

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

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

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

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

<div><h4>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>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>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>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>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>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>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>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>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>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>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>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>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>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 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>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>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>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>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>Prognostic value of myocardial performance index in individuals with type 1 and type 2 diabetes: Thousand&1 and Thousand&2 studies.</h4><i>Bahrami HSZ, Jørgensen PG, Hove JD, Dixen U, ... Rossing P, Jensen MT</i><br /><b>Aims</b><br />Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in type 1 (T1D) and type 2 diabetes (T2D). Despite diabetes affects the myocardium, risk prediction models do not include myocardial function parameters. Myocardial performance index (MPI) reflects left ventricular function. The prognostic value of MPI has not been evaluated in large-scale diabetes populations.<br /><b>Methods and results</b><br />We evaluated two prospective cohort studies: Thousand&1 (1093 individuals with T1D) and Thousand&2 (1030 individuals with T2D). Clinical data, including echocardiography, were collected at baseline. We collected follow-up data from national registries. We defined major adverse cardiovascular events (MACE) as incident events of hospital admission for acute coronary syndrome, heart failure, stroke, or all-cause mortality. For included individuals (56% male, 54 ± 15 years, MPI 0.51 ± 0.1, 63% T1D), follow-up was 100% after median of 5.3 years (range: 4.8-6.3). MPI was associated with MACE (HR 1.2, 95%CI 1.0-1.3, P = 0.012, per 0.10-unit increase) and heart failure (HR 1.3, 95%CI 1.1-1.6, P = 0.005, per 0.10-unit increase) after adjusting for clinical and echocardiographic variables. MPI predicted MACE and heart failure better in T1D than T2D (P = 0.031 for interaction). MPI added discriminatory power to the Steno T1 Risk Engine, based on clinical characteristics, in predicting MACE [area under the curve (AUC) from 0.77 to 0.79, P = 0.030] and heart failure (AUC from 0.77 to 0.83, P = 0.009) in T1D.<br /><b>Conclusion</b><br />MPI is independently associated with MACE and heart failure in T1D but not T2D and improves prediction in T1D. Echocardiographic assessment in T1D may enhance risk prediction.<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: 28 Aug 2023; epub ahead of print</small></div>

<div><h4>In memoriam Liv Hatle 1936-2023, pioneering echocardiologist.</h4><i>Fraser AG, Sutherland GR, Bijnens B</i><br /><AbstractText>In our opinion, no abstract is needed or appropriate for this article, which is a combined obituary and summary of the Liv Hatle\'s contributions to echocardiography. It does not fit into any of the categories offered by the submission website. We can provide some sentences if requested.</AbstractText><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 Aug 2023; epub ahead of print</small></div>

<div><h4>Competency-based cardiac imaging for patient-centred care. A statement of the European Society of Cardiology (ESC).</h4><i>Westwood M, Almeida AG, Barbato E, Delgado V, ... Achenbach S, Petersen SE</i><br /><AbstractText>Imaging plays an integral role in all aspects of managing heart disease and cardiac imaging is a core competency of cardiologists. The adequate delivery of cardiac imaging services requires expertise in both imaging methodology - with specific adaptations to imaging of the heart - as well as intricate knowledge of heart disease. The European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging (EACVI) of the ESC have developed and implemented a successful education and certification programme for all cardiac imaging modalities. This programme equips cardiologists to provide high quality competency-based cardiac imaging services ensuring they are adequately trained and competent in the entire process of cardiac imaging, from the clinical indication via selecting the best imaging test to answer the clinical question, to image acquisition, analysis, interpretation, storage, repository, and results dissemination. This statement emphasizes the need for competency-based cardiac imaging delivery which is key to optimal, effective and efficient, patient care.</AbstractText><br /><br />This article has been co-published with permission in the European Heart Journal, European Heart Journal – Cardiovascular Imaging, and European Heart Journal – Imaging Methods and Practice. © 2023 the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 25 Aug 2023; epub ahead of print</small></div>

<div><h4>Three-Dimensional Echocardiographic Evaluation of Longitudinal and Non-Longitudinal Components of Right Ventricular Contraction Results from the World Alliance of Societies of Echocardiography Study.</h4><i>Cotella JI, Kovacs A, Addetia K, Fabian A, ... Lang RM, WASE Investigators </i><br /><b>Aims</b><br />Right ventricular (RV) functional assessment is mainly limited to its longitudinal contraction. Dedicated 3-dimensional echocardiography (3DE) software enabled the separate assessment of the non-longitudinal components of RV ejection fraction (EF). The aims of this study were 1) to establish normal values for RV 3D-derived longitudinal, radial, and anteroposterior EF (LEF, REF, AEF respectively) and their relative contributions to global RV EF, 2) to calculate 3D RV strain normal values and, 3) to determine sex, age and race related differences in these parameters in a large group of normal subjects (WASE study).<br /><b>Methods and results</b><br />3DE RV wide-angle datasets from 1043 prospectively enrolled healthy adult subjects, were analyzed to generate a 3D mesh model of the RV cavity (TomTec). Dedicated software (ReVISION) was used to analyze RV motion along the three main anatomical planes. The EF values corresponding to each plane were identified as LEF, REF, and AEF. Relative contributions were determined by dividing each EF component by the global RVEF. RV strain analysis included longitudinal, circumferential, and global area strains (GLS, GCS and GAS, respectively). Results were categorized by sex, age (18-40, 41-65 and >65 years) and race. Absolute REF, AEF, LEF and global RVEF were higher in women than in men (p < .001). With aging, both sexes exhibited a decline in all components of longitudinal shortening (p < .001), which was partially compensated in elderly women by an increase in radial contraction. Black subjects showed lower RV EF and GAS values compared to White and Asian subjects of the same sex (p < .001) and Black men showed significantly higher RV radial but lower longitudinal contributions to global RVEF compared to Asian and White men.<br /><b>Conclusions</b><br />3DE evaluation of the non-longitudinal components of RV contraction provides additional information regarding RV physiology, including sex, age and race - related differences in RV contraction patterns that may prove useful in disease states involving the right ventricle.<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 Aug 2023; epub ahead of print</small></div>

<div><h4>Phenotyping Coronary Plaque by Computed Tomography in Premature Coronary Artery Disease.</h4><i>Rahoual G, Zeitouni M, Charpentier E, Ritvo PG, ... Redheuil A, Collet JP</i><br /><b>Aims</b><br />Premature coronary artery disease (CAD) is an aggressive disease with multiple recurrences mostly related to new coronary lesions. This study aimed to compare coronary plaque characteristics of individuals with premature CAD with those of incidental plaques found in matched individuals free of overt cardiovascular disease, using coronary computed tomography angiography (CCTA).<br /><b>Methods and results</b><br />Of 1552 consecutive individuals who underwent CCTA, 106 individuals with history of acute or stable obstructive CAD ≤45 years were matched by age, sex, smoking status, cardiovascular heredity, and dyslipidemia with 106 controls. CCTA were analyzed for CAD-RADS score, plaque composition, and high-risk plaque features (HRP), including spotty calcification, positive remodeling, low-attenuation, and napkin-ring sign. The characteristics of 348 premature CAD plaques were compared with those of 167 incidental coronary plaques of matched controls. The prevalence of non-calcified plaques was higher among individuals with premature CAD (65.1% vs. 30.2%, p < 0.001), as well as spotty calcification (42.5% vs. 17.9%, p < 0.001), positive remodeling (41.5% vs. 9.4%, p < 0.001), low-attenuation (24.5% vs. 3.8%, p < 0.001) and napkin-ring sign (1.9% vs. 0.0%). They exhibited an average of 2.2[2.7] HRP, while the control group displayed 0.4[0.8] HRP (p < 0.001). Within a median follow-up of 24[16,34] months, individuals with premature CAD and ischemic recurrence (n = 24) had more HRP (4.3[3.9]) than those without ischemic recurrence (1.5[1.9]), mostly non-calcified with low-attenuation and positive remodeling.<br /><b>Conclusion</b><br />Coronary atherosclerosis in individuals with premature CAD is characterized by a high and predominant burden of non-calcified plaque and unusual high prevalence of HRP, contributing to disease progression with multiple recurrences. A comprehensive qualitative CCTA assessment of plaque characteristics may further risk stratify our patients, beyond cardiovascular risk factors.<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 Aug 2023; epub ahead of print</small></div>

<div><h4>Correlates and Prognostic Implications of LVEF Reduction After Transcatheter Edge-to-Edge Repair for Primary Mitral Regurgitation.</h4><i>Shechter A, Kaewkes D, Lee M, Makar M, ... Makkar RR, Siegel RJ</i><br /><b>Aims</b><br />To explore the characteristics and outcomes of patients undergoing transcatheter edge-to-edge repair (TEER) for primary mitral regurgitation (MR) according to the presence of left ventricular ejection fraction (LVEF) reduction post-procedure.<br /><b>Methods and results</b><br />We retrospectively analyzed 317 individuals (median age 83 (IQR, 75-88) years, 197 (62.1%) males) treated with an isolated, first-time TEER that was concluded by a successful clip deployment. Stratified by LVEF change at 1-month compared to baseline, the cohort was evaluated for residual MR and heart failure (HF) indices up to 1-year, as well as all-cause mortality and HF hospitalizations at 2-years. Overall, 212 (66.9%) patients displayed LVEF reduction, which was mainly driven by lowered total stroke volume and diffuse hypocontractility. While postprocedural MR, transmitral mean pressure gradient, and functional status were comparable in the 2 study groups, patients with LVEF reduction exhibited a greater decline in filling pressures intra-procedurally; left ventricular mass index, pulmonary arterial systolic pressure, and serum natriuretic peptide level at 1-month; and walking limitation at 1-year. Also, by 2 years, they were less likely to die (13.3% vs 5.7%, p = 0.019), be readmitted for HF (17.1% vs 9.0%, p = 0.033), and experience either of the two (23.8% vs 12.7%, p = 0.012). Lastly, LVEF reduction was the only 1-month echocardiographic parameter to independently confer an attenuated risk for the composite of deaths or HF hospitalizations (HR 0.28, 95% CI 0.10-0.78, p = 0.016).<br /><b>Conclusion</b><br />LVEF reduction at 1-month post-TEER for primary MR is associated with better clinical outcomes, possibly reflecting a more pronounced unloading effect of the procedure.<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: 17 Aug 2023; epub ahead of print</small></div>

<div><h4>Determinants and Prognostic Implications of Left Atrial Reverse Remodeling After Coarctation of Aorta Repair in Adults.</h4><i>Egbe AC, Younis A, Miranda WR, Jain CC, Connolly HM, Borlaug BA</i><br /><b>Background</b><br />Left atrial (LA) dysfunction and atrial fibrillation are also relatively common in adults with coarctation of aorta (COA), and the severity of LA dysfunction is associated with higher risk of atrial fibrillation in this population. The purpose of this study was to determine whether LA function improved after COA repair (LA reverse remodeling), and the relationship between LA reverse remodeling and atrial fibrillation.<br /><b>Method</b><br />Retrospective cohort study of adults undergoing COA repair (2003-2020). LA reservoir strain was assessed preintervention and 12-24 months postintervention, using speckle tracking echocardiography. Incident atrial fibrillation was assessed from COA repair to last follow-up.<br /><b>Results</b><br />Of 261 adults that underwent COA repair (age 37 ± 13 years; males 148 [57%]), 124 (47%) and 137 (53%) presented with native versus recurrent COA, respectively. Of 261 patients, 231 (82%) and 48 (18%) underwent surgical and transcatheter COA repair, respectively. LA reservoir strain increased from 32 ± 8% (preintervention) to 39 ± 7% (post intervention), yielding a relative increase of 21 ± 5%. Older age (β±SE -0.16 ± 0.09 per 5-year, p = 0.02), higher systolic blood pressure (β±SE -0.12 ± 0.04 per 5 mmHg, p = 0.005), and higher residual COA mean gradient (β±SE -0.17 ± 0.06 per 5 mmHg, p = 0.002) postintervention were associated with less LA reverse remodeling, after adjustment for sex, hypertension diagnosis, and left ventricular indices. LA reverse remodeling (hazard ratio 0.97, 95% confidence interval 0.96-0.98 per 1% increase from preintervention LA function, p = 0.006) was associated with lower risk of atrial fibrillation after adjustment for age, sex, preintervention LA reservoir strain, and history of atrial fibrillation.<br /><b>Conclusions</b><br />COA repair resulted in improved LA function and decreased risk for atrial fibrillation, especially in patients without residual hypertension or significant residual COA gradient.<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: 16 Aug 2023; epub ahead of print</small></div>

<div><h4>The Diagnostic Performance of QFR and Perfusion Imaging in Patients with Prior Coronary Artery Disease.</h4><i>van Diemen PA, de Winter RW, Schumacher SP, Everaars H, ... Driessen RS, Danad I</i><br /><b>Aims</b><br />In chronic coronary syndrome (CCS) patients with documented coronary artery disease (CAD) ischemia detection by myocardial perfusion imaging (MPI) or an invasive approach are viable diagnostic strategies. We compared the diagnostic performance of quantitative flow ratio (QFR) with single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (CMR) in patients with prior CAD (previous percutaneous coronary intervention (PCI) and/or myocardial infarction (MI)).<br /><b>Methods and results</b><br />This PACIFIC-2 substudy evaluated 189 CCS patients with prior CAD for inclusion. Patients underwent SPECT, PET, and CMR followed by invasive coronary angiography with fractional flow reserve measurements of all major coronary arteries (N=567) except for vessels with a subtotal or chronic total occlusion. QFR computation was attempted in 488 (86%) vessels with measured FFR available (FFR ≤0.80 defined hemodynamically significant CAD). QFR analysis was successful in 334 (68%) vessels among 166 patients and demonstrated a higher accuracy (84%) and sensitivity (72%) compared to SPECT (66%, p<0.001 and 46%, p=0.001), PET (65%, p<0.001 and 58%, p=0.032), and CMR (72%, p<0.001 and 33%, p<0.001). Specificity of QFR (87%) was similar to CMR (83%, p=0.123) but higher than that of SPECT (71%, p<0.001) and PET (67%, p<0.001). Lastly, QFR exhibited a higher area under the receiver operating characteristic curve (0.89) than SPECT (0.57, p<0.001), PET (0.66, p<0.001), and CMR (0.60, p<0.001).<br /><b>Conclusion</b><br />QFR correlated better with FFR in patients with prior CAD than MPI, as reflected in the higher diagnostic performance measures for detecting FFR-defined vessel-specific significant 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: 14 Aug 2023; epub ahead of print</small></div>

<div><h4>Late gadolinium enhancement distribution patterns in non-ischemic dilated cardiomyopathy: Genotype-phenotype correlation.</h4><i>de Frutos F, Ochoa JP, Fernández AI, Gallego-Delgado M, ... Garcia-Pavia P, Mirelis JG</i><br /><b>Aims</b><br />Late gadolinium enhancement (LGE) is frequently found in patients with dilated cardiomyopathy (DCM), there is little information about its frequency and distribution pattern according to underlying genetic substrate. We sought to describe LGE patterns according to genotype and to analyze the risk of major ventricular arrhythmias (MVA) according to patterns.<br /><b>Methods and results</b><br />Cardiac magnetic resonance findings and LGE distribution according to genetics was performed in a cohort of 600 DCM patients followed at 20 Spanish centers. After exclusion of individuals with multiple causative gene variants or with variants in infrequent DCM-causing genes, 577 patients (34% females, mean age 53.5 years, LVEF 36.9 ± 13.9%) conformed the final cohort. A causative genetic variant was identified in 219 (38%) patients and 147 (25.5%) had LGE. Significant differences were found comparing LGE patterns between genes (P < 0.001). LGE was absent or rare in patients with variants in TNNT2, RBM20 and MYH7 (0%, 5% and 20%, respectively). Patients with variants in DMD, DSP and FLNC showed predominance of LGE subepicardial pattern (50%, 41% and 18%, respectively) whereas patients with variants in TTN, BAG3, LMNA and MYBPC3 showed unspecific LGE patterns. Genetic yield differed according to LGE pattern. Patients with subepicardial, lineal midwall, transmural, right ventricular insertion points or with combination of LGE patterns showed increased risk of MVA compared with patients without LGE.<br /><b>Conclusion</b><br />LGE patterns in DCM has a specific distribution according to the affected gene. Certain LGE patterns are associated with increased risk of MVA and with increased yield of genetic testing.<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: 10 Aug 2023; epub ahead of print</small></div>

<div><h4>Gene-Echocardiography: Refining Genotype-Phenotype Correlations in Hypertrophic Cardiomyopathy.</h4><i>Zhou N, Weng H, Zhao W, Tang L, ... Pan C, Shu X</i><br /><b>Aims</b><br />This study aims to clarify the association between hypertrophic patterns and genetic variants in hypertrophic cardiomyopathy (HCM) patients, contributing to the advancement of personalized management strategies for HCM.<br /><b>Methods and results</b><br />A comprehensive evaluation of genetic mutations was conducted in 392 HCM-affected families using Whole Exome Sequencing. Concurrently, relevant echocardiographic data from these individuals were collected. Our study revealed an increased susceptibility to enhanced septal and interventricular septal thickness in HCM patients harboring gene mutations compared to those without. Mid-septal hypertrophy was found to be associated predominantly with MYBPC3 variants, while a higher septum-to-posterior wall ratio correlated with MYH7 variants. Mutations in MYH7, MYBPC3, and other sarcomeric or myofilament genes (TNNI3, TPM1, TNNT2) showed a relationship with increased hypertrophy in the anterior wall, interventricular septum, and lateral wall of the left ventricle. In contrast, ALPK3-associated hypertrophy chiefly presented in the apical region, while hypertrophy related to TTN and OBSCN mutations exhibited a uniform distribution across the myocardium. Hypertrophic patterns varied with the type and category of gene mutations, offering valuable diagnostic insights.<br /><b>Conclusion</b><br />Our findings underscore a strong link between hypertrophic patterns and genetic variants in HCM, providing a foundation for more accurate genetic testing and personalized management of HCM patients. The novel concept of \"gene-echocardiography\" may enhance the precision and efficiency of genetic counseling and testing in HCM.<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: 10 Aug 2023; epub ahead of print</small></div>

<div><h4>Incident atrial functional mitral regurgitation in atrial fibrillation and sinus rhythm.</h4><i>Naser JA, Michelena HI, Lin G, Scott CG, ... Nkomo VT, Pislaru SV</i><br /><b>Aims</b><br />Atrial functional mitral regurgitation (AFMR) has been associated with atrial fibrillation (AF) and heart failure with preserved ejection fraction. However, data on incident AFMR are scarce. We aimed to study the incidence, risk factors and clinical significance of AFMR in AF or sinus rhythm (SR).<br /><b>Methods and results</b><br />Adults with new diagnosis of AF and adults in SR were identified. Patients with >mild MR at baseline, primary mitral disease, cardiomyopathy, left-sided valve disease, previous cardiac surgery, or with no follow-up echocardiogram were excluded. Diastolic dysfunction was indicated by ≥2/4 abnormal diastolic function parameters [mitral medial e\', mitral medial E/e\', tricuspid regurgitation velocity, left atrial volume index]. Overall, 1,747 patients with AF and 29,623 in SR were included. Incidence rate of >mild AFMR was 2.6 per 100-person year in AF and 0.7 per 100-person year in SR, p<.001. AF remained associated with AFMR in a propensity-score matched analysis based on age, sex, and comorbidities between AF and SR [hazard ratio: 3.80 (95% CI 3.04-4.76)]. Independent risk factors associated with incident AFMR were age ≥65 years, female sex, left atrial volume index, and diastolic dysfunction in both AF and SR, in addition to rate (vs rhythm) control in AF. Incident AFMR was independently associated with all-cause death in both groups (both p<.001).<br /><b>Conclusions</b><br />AF conferred three-fold increase in the risk of incident AFMR. Diastolic dysfunction, older age, left atrial size, and female sex were independent risk factors in both SR and AF, while rhythm control was protective. AFMR was universally associated with worse mortality.<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: 09 Aug 2023; epub ahead of print</small></div>

<div><h4>Myocardial structural and functional changes in cardiac amyloidosis - Insights from a prospective observational patient registry.</h4><i>Duca F, Rettl R, Kronberger C, Binder C, ... Kammerlander AA, Bonderman D</i><br /><b>Aims</b><br />The pathophysiological hallmark of cardiac amyloidosis (CA) is the deposition of amyloid within the myocardium. Consequently, extracellular volume (ECV) of affected patients increases. However, studies on ECV progression over time are lacking.We aimed to investigate the progression of ECV and its prognostic impact in CA patients.<br /><b>Methods and results</b><br />Serial cardiac magnetic resonance (CMR) examinations, including ECV quantification were performed in consecutive CA patients.Between 2012 and 2021, 103 CA patients underwent baseline and follow-up CMR, including ECV quantification.Median ECVs at baseline of the total (n = 103), transthyretin [(ATTR) n = 80], and [light chain (AL) n = 23] CA cohorts were 48.0%, 49.0%, and 42.6%. During a median period of 12 months, ECV increased significantly in all cohorts [change (Δ) + 3.5% interquartile range (IQR): -1.9 - + 6.9, p < 0.001; Δ + 3.5%, IQR: -2.0 - + 6.7, p < 0.001; Δ + 3.5%, IQR: -1.6 - + 9.1, p = 0.026). Separate analyses for treatment-naïve (n = 21) and treated (n = 59) ATTR patients revealed that the median change of ECV from baseline to follow-up was significantly higher among untreated patients (+5.7% versus +2.3%, p = 0.004).Survival analyses demonstrated that median change of ECV was a predictor of outcome [total: hazard ratio (HR): 1.095, 95% confidence-interval (CI): 1.047-1.0145, p < 0.001; ATTR: HR: 1.073, 95% CI: 1.015-1.134, p = 0.013; AL: HR: 1.131, 95% CI: 1.041-1.228, p = 0.003].<br /><b>Conclusion</b><br />The present study supports the use of serial ECV quantification in CA patients, as change of ECV was a predictor of outcome and could provide information in the evaluation of amyloid-specific treatments.<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: 07 Aug 2023; epub ahead of print</small></div>

<div><h4>Phenotyping heart failure by echocardiography: Imaging of ventricular function and haemodynamics at rest and exercise.</h4><i>Smiseth OA, Donal E, Boe E, Ha JW, Fernandes JF, Lamata P</i><br /><AbstractText>Traditionally, congestive heart failure was phenotyped by echocardiography or other imaging techniques according to left ventricular ejection fraction (LVEF). The more recent echocardiographic modality speckle tracking strain is complementary to LVEF, as it is more sensitive to diagnose mild systolic dysfunction. Furthermore, when LV systolic dysfunction is associated with a small, hypertrophic ventricle, EF is often normal or supernormal, whereas LV global longitudinal strain can reveal reduced contractility. In addition, segmental strain patterns may be used to identify specific cardiomyopathies which in some cases can be treated with patient-specific medicine. In heart failure with preserved LVEF (HFpEF), a diagnostic hallmark is elevated LV filling pressure, which can be diagnosed with good accuracy by applying a set of echocardiographic parameters. When patients with HFpEF often have normal filling pressure at rest, a non-invasive or invasive diastolic stress test may be used to identify abnormal elevation of filling pressure during exercise. The novel parameter LV work index which incorporates afterload, is a promising tool for quantification of LV contractile function and efficiency. Another novel modality is shear wave imaging for diagnosing stiff ventricles, but clinical utility remains to be determined. In conclusion, echocardiographic imaging of cardiac function should include LV strain as a supplementary method to LVEF. Echocardiographic parameters can identify elevated LV filling pressure with good accuracy and may be applied in the diagnostic work-up of patients suspected of HFpEF.</AbstractText><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: 05 Aug 2023; epub ahead of print</small></div>

<div><h4>Right Ventricular Myocardial Work for the Prediction of Early Right Heart Failure and Long-term Mortality After Left Ventricular Assist Device Implant.</h4><i>Landra F, Sciaccaluga C, Pastore MC, Gallone G, ... Cameli M, Mandoli GE</i><br /><b>Aims</b><br />Right heart failure(RHF) after LVAD implant is burdened by high morbidity and mortality rates and should be prevented by appropriate patient selection. Adequate right ventricular(RV) function is of paramount importance but its assessment is complex and cannot disregard afterload. Myocardial Work(MW) is a non-invasive Speckle Tracking Echocardiography-derived method to estimate pressure-volume loops. The aim of this study was to evaluate the performance of RVMW to predict RHF and long-term mortality after LVAD implant.<br /><b>Methods and results</b><br />Consecutive patients from May 2017 to February 2022 undergoing LVAD implant were retrospectively reviewed. Patients without a useful echocardiographic exam prior to LVAD implant were excluded. MW analysis was performed. The primary endpoints were early RHF (<30 days from LVAD implant) and death at latest available follow-up. We included 23 patients (mean age 64 ± 8 years, 91% men). Median follow-up was 339 days (IQR: 30-1143). Early RHF occurred in 6 patients (26%). A lower RV Global Work Efficiency(RVGWE, OR 0.86, 95% CI 0.76-0.97, p = 0.014) was associated with the occurrence of early RHF. Among MW indices, performance for early RHF prediction was greatest for RVGWE (AUC 0.92) and a cut-off of 77% had a 100% sensitivity and 82% specificity. At long term follow-up, death occurred in 4 of 14 patients (28.6%) in the RVGWE > 77% group and in 6 of 9 patients (66.7%) in the RVGWE < 77% group (HR 0.25, 95% CI 0.07-0.90, p = 0.033).<br /><b>Conclusion</b><br />RVGWE was a predictor of early RHF after LVAD implant and brought prognostic value in terms of long-term mortality.<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 Aug 2023; epub ahead of print</small></div>

<div><h4>Normal Reference Values for Mitral Annular Plane Systolic Excursion by M-mode and Speckle-Tracking Echocardiography: A Prospective, Multicenter, Population-Based Study.</h4><i>Wang YH, Sun L, Li SW, Wang CF, ... Ren WD, Study Investigators </i><br /><b>Aims</b><br />Mitral annular plane systolic excursion (MAPSE) is a simple and reliable index for evaluating left ventricular (LV) systolic function, particularly in patients with poor image quality; however, the lack of reference values limits its widespread use. This study aimed to establish the normal ranges for MAPSE measured using motion mode (M-mode) and two-dimensional speckle-tracking echocardiography (2D-STE) and to explore its principal determinants.<br /><b>Methods and results</b><br />This multicenter, prospective, cross-sectional study included 1,952 healthy participants (840 men [43%]; age range, 18-80 years) from 55 centers. MAPSE was measured using M-mode echocardiography and 2D-STE. The results showed that women had a higher MAPSE than men and MAPSE decreased with age. The age- and sex-specific reference values for MAPSE were established for these two methods. Multiple linear regression analyses revealed that MAPSE on M-mode echocardiography correlated with age and MAPSE on 2D-STE with age, blood pressure, heart rate, and LV volume. Moreover, MAPSE measured by 2D-STE correlated more strongly with global longitudinal strain compared with that measured using M-mode echocardiography.<br /><b>Conclusion</b><br />Normal MAPSE reference values were established based on age and sex. Blood pressure, heart rate, and LV volume are potential factors that influence MAPSE and should be considered in clinical practice. Normal values are useful for evaluating the LV longitudinal systolic function, especially in patients with poor image quality, and may further facilitate the use of MAPSE in routine assessments.<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: 02 Aug 2023; epub ahead of print</small></div>

<div><h4>CMR Reclassifies the Majority of Patients with Suspected MINOCA and non MINOCA.</h4><i>Liang K, Bisaccia G, Leo I, Williams MGL, ... Johnson TW, Bucciarelli-Ducci C</i><br /><b>Background</b><br />In approximately 5-15% of all cases of acute coronary syndromes (ACS) have unobstructed coronaries on angiography. Cardiac magnetic resonance (CMR) has proven useful to identify in most patients the underlying diagnosis associated with this presentation. However, the role of CMR to reclassify patients from the initial suspected condition has not been clarified.<br /><b>Aims</b><br />The aim of this study was to assess the proportion of patients with suspected MINOCA, or non-MINOCA, that CMR reclassifies with an alternative diagnosis from the original clinical suspicion.<br /><b>Methods and results</b><br />A retrospective cohort of patients in a tertiary cardiology centre was identified from a registry database. Patients who were referred for CMR for investigation of suspected MINOCA, and a diagnosis pre- and post-CMR was recorded to determine the proportion of diagnoses reclassified.A total of 888 patients were identified in the registry. CMR reclassified diagnosis in 78% of patients. Diagnosis of MINOCA was confirmed in only 243 patients (27%), whilst most patients had an alternative diagnosis (73%): myocarditis n = 217 (24%), Takotsubo syndrome n = 115 (13%), cardiomyopathies n = 97 (11%), normal CMR/non-specific n = 216 (24%).<br /><b>Conclusion</b><br />In a large single-centre cohort of patients presenting with acute coronary syndrome and unobstructed coronary arteries, most patients had a non-MINOCA diagnosis (73%) (myocarditis, TakoTsubo, cardiomyopathies or normal CMR/non-specific findings), whilst only a minority had confirmed MINOCA (27%). Performing CMR led to reclassifying patients\' diagnosis in 78% of cases, thus confirming its important clinical role and underscoring the clinical challenge in diagnosing MINOCA and non MINOCA conditions.<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: 01 Aug 2023; epub ahead of print</small></div>

<div><h4>Systolic anterior motion of the anterior mitral valve leaflet begins in subclinical hypertrophic cardiomyopathy.</h4><i>Seitler S, De Zoysa Anthony S, Obianyo CCC, Syrris P, ... Moon JC, Captur G</i><br /><b>Aims</b><br />Anterior mitral valve leaflet (AMVL) elongation is detectable in overt and subclinical hypertrophic cardiomyopathy (HCM). We sought to investigate the dynamic motion of the aorto-mitral apparatus to understand the behaviour of the AMVL, and mechanisms of left ventricular outflow tract obstruction (LVOTO) predisposition in HCM.<br /><b>Methods & results</b><br />Cardiovascular magnetic resonance imaging (CMR) using 1.5 Tesla scanner was performed on 36 HCM sarcomere gene mutation carriers without left ventricular hypertrophy (G + LVH-), 31 HCM patients with preserved ejection fraction carrying a pathogenic sarcomere gene mutation (G + LVH+), and 53 age, sex and BSA-matched healthy volunteers.Dynamic excursion of the aorto-mitral apparatus was assessed semi-automatically on breath-held 3-chamber cine steady-state free precession images. Four pre-defined regions of interest (ROI) were tracked: ROIPMVL: hinge point of the posterior MVL; ROITRIG: intertrigonal mitral annulus; ROIAMVL: AMVL tip; ROIAAO: anterior aortic annulus. Compared to controls, normalized two-dimensional displacement-versus-time plots in G + LVH- revealed subtle but significant systolic anterior motion (SAM) of the AMVL (P < 0.0001) and reduced longitudinal excursion of ROIAAO (P = 0.014) and ROIPMVL (P = 0.048). In overt and subclinical HCM, excursion of the ROITRIG/AMVL/PMVL was positively associated with burden of LV fibrosis (p < 0.028). As expected, SAM was observed in G + LVH + together with reduced longitudinal excursion of ROITRIG (P = 0.049) and ROIAAO (P = 0.008).<br /><b>Conclusion</b><br />Dyskinesia of the aorto-mitral apparatus, including SAM of the elongated AMVL, is detectable in subclinical HCM, before the development of LVH or LA enlargement. These data have the potential to improve our understanding of early phenotype development and LVOTO-predisposition in HCM.<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: 31 Jul 2023; epub ahead of print</small></div>

<div><h4>Efficacy on resynchronization and longitudinal contractile function comparing His-bundle pacing to conventional biventricular pacing. - A substudy to the His-alternative study.</h4><i>Højgaard EV, Philbert BT, Linde JJ, Winsløw UC, ... Vinther M, Risum N</i><br /><b>Aims</b><br />His-bundle pacing has emerged as a novel method to deliver cardiac resynchronization therapy (CRT). However, there are no data comparing conventional Biventricular (BiV)-CRT to His-CRT with regards to effects on mechanical dyssynchrony and longitudinal contractile function.<br /><b>Methods and results</b><br />Patients with symptomatic heart failure, left ventricular ejection fraction (LVEF) ≤ 35% and left bundle branch block (LBBB) by strict ECG criteria were randomized 1:1 to His-CRT or BiV-CRT. Two-dimensional strain echocardiography was performed prior to CRT implantation and at six months after implantation. Differences in changes in mechanical dyssynchrony (standard deviation of time-to-peak in 12 midventricular and basal segments) and regional longitudinal strain in the six left ventricular walls were compared between the BiV-CRT and His-CRT groups.In the on treatment analysis 31 received BiV-CRT and 19 His-CRT. In both groups mechanical dyssynchrony was significantly reduced after six months (BiV-group from 120 ms [±45] to 63 ms [±22], P < 0.001, His-group from 116 ms [±54] to 49 ms [±11], P < 0.001), but no significant differences in changes could be demonstrated between groups (-9.0 ms [-36; 18], P = 0.50). GLS improved in both groups (BiV-group from -9.1% [±2.7] to -10.7% [±2.6], P = 0.02, and His-group from -8.6% [±2.1] to -11.1% [±2.0], P < 0.001) but no significant differences in changes could be demonstrated from baseline to follow-up (-0.9 [-2.4; -0.6], P = 0.25) between groups. There were no regional differences between groups (P < 0.05, all).<br /><b>Conclusions</b><br />In heart failure patients with LBBB, BiV-CRT and His-CRT have comparable effects with regards to improvements in mechanical dyssynchrony and longitudinal contractile function.<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 Jul 2023; epub ahead of print</small></div>

<div><h4>Global Constructive Work is associated with ventricular arrythmias after cardiac resynchronization therapy.</h4><i>Saffi H, Winsløw U, Sakthivel T, Højgaard EV, ... Bundgaard H, Risum N</i><br /><b>Aim</b><br />Non-invasive left ventricular (LV) pressure-strain loops provide a novel method for quantifying myocardial work by incorporating LV pressure in measurements of myocardial deformation. Early studies suggest that myocardial work parameters such as Global Constructive Work (GCW) could be useful and reliable in arrhythmia prediction particularly in patients undergoing cardiac resynchronization therapy.The aim of this study was to evaluate whether the magnitude of GCW was associated with occurrence of ventricular arrhythmias in patients after cardiac resynchronization therapy.<br /><b>Method and results</b><br />Patients on guideline-recommended treatment with a cardiac resynchronization therapy defibrillator (CRT-D) were evaluated by 2D speckle-tracking echocardiography including measurements of GCW at least six months after implantation. The primary outcome was a composite of appropriate defibrillator therapy and sustained ventricular arrhythmia under the monitor zone. A total of 162 patients (mean age 66 years (±10), 122 males (75%)), were included. 16 (10%) patients experienced the primary outcome during a median follow-up of 18 months (IQR: 12-25) after the index echocardiography. Patients with below-median GCW (<1,473 mmHg%) had a hazard ratio for the outcome of 8.14 [95% CI: 1.83-36.08], P = 0.006 compared to patients above the median in a univariate model and remained an independent predictor after multivariate adjustment for eGFR and QRS duration (hazard ratio 4.75 [95% CI: 1.01-22.28], P < 0.05.<br /><b>Conclusion</b><br />In patients treated with CRT-D, GCW below median level was associated with a 5-fold increase in risk of ventricular arrhythmias.<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 Jul 2023; epub ahead of print</small></div>

<div><h4>Prognostic value of global myocardial flow reserve in patients with history of coronary artery bypass grafting.</h4><i>Al Rifai M, Ahmed AI, Saad JM, Alahdab F, Nabi F, Al-Mallah MH</i><br /><b>Aims</b><br />It is not well understood whether positron emission tomography (PET)-derived myocardial flow reserve (MFR) is prognostic among patients with prior coronary artery bypass grafting (CABG).<br /><b>Methods and results</b><br />Consecutive patients with a clinical indication for PET were enrolled in the Houston Methodist DeBakey Heart and Vascular Center PET registry and followed prospectively for incident outcomes. The primary outcome was a composite of all-cause death, myocardial infarction (MI)/unplanned revascularization, and heart failure admissions. Cox proportional hazards models were used to study the association between MFR (<2 vs. ≥2) and incident events adjusting for clinical and myocardial perfusion imaging variables. The study population consisted of 836 patients with prior CABG; mean (SD) age 68 (10) years, 53% females, 79% Caucasian, 36% non-Hispanic, and 66% with MFR <2. Over a median (interquartile range [IQR]) follow-up time of 12 (4-24) months, there were 122 incident events (46 HF admissions, 28 all-cause deaths, 23 MI, 22 PCI/3 repeat CABG 90 days after imaging). In adjusted analyses, patients with impaired MFR had a higher risk of the primary outcome [hazard ratio (HR) 2.06; 95% CI 1.23-3.44]. Results were significant for admission for heart failure admissions (HR 2.92; 95% CI 1.11-7.67) but not for all-cause death (HR 2.01, 95% CI 0.85-4.79), or MI/UR (HR 1.93, 95% CI 0.92-4.05).<br /><b>Conclusion</b><br />Among patients with a history of CABG, PET-derived global MFR <2 may identify those with a high risk of subsequent cardiovascular events, especially heart failure, independent of cardiovascular risk factors and perfusion data.<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 Jul 2023; epub ahead of print</small></div>

<div><h4>The added value of abnormal regional myocardial function for risk prediction in arrhythmogenic right ventricular cardiomyopathy.</h4><i>Kirkels FP, Rootwelt-Norberg C, Bosman LP, Aabel EW, ... Haugaa K, Teske AJ</i><br /><b>Background:</b><br/>& aims</b><br />A risk calculator for individualized prediction of first-time sustained ventricular arrhythmia (VA) in arrhythmogenic right ventricular cardiomyopathy (ARVC) patients has recently been developed and validated (www.ARVCrisk.com). This study aimed to investigate whether regional functional abnormalities, measured by echocardiographic deformation imaging, can provide additional prognostic value.<br /><b>Methods & results</b><br />From two referral centres, 150 consecutive patients with a definite ARVC diagnosis, no prior sustained VA and an echocardiogram suitable for deformation analysis were included (aged 41±17 years, 50% female). During a median follow-up of 6.3 (IQR 3.1-9.8) years, 37 (25%) experienced a first-time sustained VA. All tested left and right ventricular (LV, RV) deformation parameters were univariate predictors for first-time VA. While LV function did not add predictive value in multivariate analysis, two RV deformation parameters did; RV free wall longitudinal strain and regional RV deformation patterns remained independent predictors after adjusting for the calculator-predicted risk (HR 1.07 [1.02-1.11]; p = 0.004 and 4.45 [1.07-18.57]; p = 0.040, respectively) and improved its discriminative value (from C-statistic 0.78 to 0.82 in both. Akaike information criterion change >2). Importantly, all patients who experienced VA within 5 years from the echocardiographic assessment had abnormal regional RV deformation patterns at baseline.<br /><b>Conclusions</b><br />This study showed that regional functional abnormalities measured by echocardiographic deformation imaging can further refine personalized arrhythmic risk prediction when added to the ARVC risk calculator. The excellent negative predictive value of normal RV deformation could support clinicians considering timing of ICD implantation in patients with intermediate arrhythmic risk.<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: 20 Jul 2023; epub ahead of print</small></div>

<div><h4>Left ventricular-global longitudinal strain as a prognosticator in hypertrophic cardiomyopathy with a low-normal left ventricular ejection fraction.</h4><i>Choi YJ, Lee HJ, Park JS, Park CS, ... Hwang IC, Kim HK</i><br /><b>Aims</b><br />To investigate the prognostic utility of left ventricular (LV)-global longitudinal strain (LV-GLS) in patients with hypertrophic cardiomyopathy (HCM) and an LV-ejection fraction (LVEF) of 50-60%.<br /><b>Methods and results</b><br />This retrospective cohort study included 349 patients with HCM and an LVEF of 50-60%. The primary outcome was a composite of cardiovascular death, including sudden cardiac death (SCD), and SCD-equivalent events. The secondary outcomes were SCD/SCD-equivalent events, cardiovascular death (including SCD), and all-cause death. The final analysis included 349 patients (mean age 59.2 ± 14.2 years, men 75.6%). During a median follow-up of 4.1 years, the primary outcome occurred in 26 (7.4%), while the secondary outcomes of SCD/SCD-equivalent events, cardiovascular death, and all-cause death occurred in 15 (4.2%), 20 (5.7%), and 34 (9.7%), respectively. After adjusting for age, atrial fibrillation, ischemic stroke, LVEF, and left atrial volume index, absolute LV-GLS (%) was independently associated with the primary outcome (adjusted HR 0.88, 95% CI 0.788-0.988, P = 0.029). According to receiver operating characteristic analysis, 10.5% is an optimal cutoff value for absolute LV-GLS in predicting the primary outcome. Patients with an absolute LV-GLS ≤ 10.5% had a higher risk of the primary outcome than those with an absolute LV-GLS > 10.5% (adjusted HR 2.54, 95% CI 1.117-5.787, P = 0.026). Absolute LV-GLS ≤10.5% was an independent predictor for each secondary outcome (P < 0.05).<br /><b>Conclusions</b><br />LV-GLS was an independent predictor of a composite of cardiovascular death, including SCD/SCD-equivalent events, in patients with HCM and an LVEF of 50-60%. Therefore, LV-GLS can help in risk stratification in these patients.<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 Jul 2023; epub ahead of print</small></div>

<div><h4>Tales from the future - Nuclear cardio-oncology, from prediction to diagnosis and monitoring.</h4><i>Mikail N, Chequer R, Imperiale A, Meisel A, ... Gebhard C, Rossi A</i><br /><AbstractText>Cancer and cardiovascular disease often share common risk factors, and patients with cardiovascular disease who develop cancer are at high risk of experiencing major adverse cardiac events. Additionally, cancer treatment can induce short- and long-term adverse cardiovascular events. Given the improvement in oncological patients\' prognosis, the burden in this vulnerable population is slowly shifting towards increased cardiovascular mortality. Consequently, the field of cardio-oncology is steadily expanding, prompting the need for new markers to stratify and monitor the cardiovascular risk in oncological patients before, during, and after the completion of treatment. Advanced noninvasive cardiac imaging has raised great interest in the early detection of cardiovascular diseases and cardiotoxicity in oncological patients. Nuclear medicine has long been a pivotal exam to robustly assess and monitor the cardiac function of patients undergoing potentially cardiotoxic chemotherapies. In addition, recent radiotracers have shown great interest in the early detection of cancer treatment-related cardiotoxicity. In this review, we summarize the current and emerging nuclear cardiology tools that can help identify cardiotoxicity and assess the cardiovascular risk in patients undergoing cancer treatments, and discuss the specific role of nuclear cardiology alongside other noninvasive imaging techniques.</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: 19 Jul 2023; epub ahead of print</small></div>

<div><h4>Current Clinical Use of Speckle Tracking Strain Imaging: Insights from a Worldwide Survey from the European Association of Cardiovascular Imaging-EACVI.</h4><i>Sade LE, Joshi SS, Cameli M, Cosyns B, ... Sitges M, Dweck MR</i><br /><b>Background</b><br />Echocardiographic speckle-tracking strain imaging (STE) has been a major advance in myocardial function quantification. We aimed to explore current world-wide clinical application of STE.<br /><b>Methods</b><br />Access, feasibility, access, and clinical implementation of STE were investigated with a worldwide open-access online survey of the European Association of Cardiovascular Imaging (EACVI).<br /><b>Results</b><br />Participants (429 respondents, 77 countries) from tertiary centers (46%), private clinics or public hospitals (54%) using different vendors for data acquisition and analysis were represented. Despite almost universal access (98%) to STE, only 39% of the participants performed and reported STE results frequently (>50%). Incomplete training and time constraints were the main reasons for not using STE more regularly. STE was mainly used to assess the left ventricular (99%) and less frequently the right ventricular (57%) and the left atrial (46%) function. Cardiotoxicity (88%) and cardiac amyloidosis (87%) were the most frequent reasons for the clinical use of left ventricular STE. Left atrial STE was used most frequently for the diagnosis of diastolic dysfunction and right ventricular STE for the assessment of RV function in pulmonary hypertension (51%). Frequency of STE use, adherence to optimal techniques and clinical appropriateness of STE differed according to training experience and across vendors. Key suggestions outlined by respondents to increase the clinical use of STE included improved reproducibility (48%) and standardization of strain values across vendors (42%).<br /><b>Conclusions</b><br />Although STE is now readily available, it is underutilized in the majority of centers. Structured training, improved reproducibility and inter-vendor standardization may increase its uptake.<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: 18 Jul 2023; epub ahead of print</small></div>

<div><h4>Clinical Impact of OCT-Derived Suboptimal Stent Implantation Parameters and Definitions.</h4><i>Romagnoli E, Burzotta F, Vergallo R, Gatto L, ... Stone GW, Prati F</i><br /><b>Aims</b><br />Despite growing evidence supporting the clinical utility of optical coherence tomography (OCT)-guidance during percutaneous coronary interventions (PCIs), there is no common agreement as to the optimal stent implantation parameters that enhance clinical outcome.<br /><b>Methods and results</b><br />We retrospectively examined the predictive accuracy of suboptimal stent implantation definitions proposed from the CLI-OPCI II, ILUMIEN-IV OPTIMAL PCI, and FORZA studies for the long-term risk of device oriented cardiovascular events (DoCE) in the population of large all-comers CLI-OPCI project.A total of 1020 patients undergoing OCT-guided drug-eluting stent implantation in the CLI-OPCI registry with a median follow-up of 809 (quartiles 414-1376) days constituted the study population. According to CLI-OPCI II, ILUMIEN-IV OPTIMAL PCI, and FORZA criteria, the incidence of suboptimal stent implantation was31.8%, 58.1%, and 57.8%, respectively. By multivariable Cox analysis, suboptimal stent implantation criteria from the CLI-OPCI II (hazard ratio 2.75 [95% confidence interval 1.88-4.02], p<0.001) and ILUMIEN-IV OPTIMAL PCI (1.79 [1.18-2.71], p=0.006) studies, but not FORZA trial (1.11 [0.75-1.63], p=0.597), were predictive of DoCE. At long-term follow-up, stent edge disease with minimum lumen area <4.5mm2 (8.17 [5.32-12.53], p<0.001), stent edge dissection (2.38 [1.33-4.27], p=0.004) and minimum stent area <4.5mm2 (1.68 [1.13-2.51], p=0.011) were the main OCT predictors of DoCE.<br /><b>Conclusion</b><br />The clinical utility of OCT-guided PCI might depend on the metrics adopted to define suboptimal stent implantation. Uncovered disease at the stent border, stent edge dissection, and minimum stent area <4.5mm2 were the strongest OCT associates of stent failure.<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: 18 Jul 2023; epub ahead of print</small></div>

<div><h4>Prognostic significance of subpulmonary left ventricular size and function in patients with a systemic right ventricle.</h4><i>Surkova E, Constantine A, Xu Z, Segura de la Cal T, ... Dimopoulos K, Li W</i><br /><b>Aim</b><br />To assess the additional prognostic significance of echocardiographic parameters of subpulmonary left ventricular (LV) size and function in patients with a systemic right ventricle (SRV).<br /><b>Methods and results</b><br />All adults with a SRV who underwent transthoracic echocardiography in 2010-2018 at a large tertiary center were identified. Biventricular size and function were assessed at the most recent exam. The study endpoint was all-cause mortality or heart/heart-lung transplantation.We included 180 patients, 100(55.6%) male, mean age 42.4±12.3 years, of whom 103(57.2%) had undergone Mustard/Senning operations and 77(42.8%) had congenitally corrected transposition of great arteries.Over 4.9[3.8-5.7] years, 28(15.6%) patients died and 4(2.2%) underwent heart or heart-lung transplantation. Univariable predictors of the study endpoint included age, NYHA functional class III or IV, history of atrial arrhythmias, presence of pacemaker or cardioverter-defibrillator, high BNP, and echocardiographic markers of SRV and subpulmonary LV size and function. On multivariable Cox analysis of echocardiographic variables, indexed LV end-systolic diameter (ESDi; HR 2.77 [95%CI 1.35-5.68], p=0.01), LV fractional area change (FAC; HR 0.7 [95%CI 0.57-0.85], p=0.002), SRV basal diameter (HR 1.66 [95%CI 1.21-2.29], p=0.005), and SRV FAC (HR 0.65 [95%CI 0.49-0.87], p=0.008) remained predictive of mortality or transplantation. On ROC analysis, subpulmonary LV parameters performed better than SRV markers in predicting adverse events.<br /><b>Conclusions</b><br />SRV basal diameter, SRV FAC, LV ESDi, and LV FAC are significantly and independently associated with mortality and transplantation in adults with a SRV. Accurate echocardiographic assessment of both SRV and subpulmonary LV is therefore essential to inform risk stratification and management.<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: 15 Jul 2023; epub ahead of print</small></div>

<div><h4>Abnormal release of cardiac biomarkers in the presence of myocardial edema evaluated by cardiac magnetic resonance after uncomplicated revascularization procedures.</h4><i>Ribas FF, Hueb W, Rezende PC, Rochitte CE, ... Franchini Ramires JA, Kalil-Filho R</i><br /><b>Aims</b><br />To analyze the association of myocardial edema (ME), observed as high T2-signal intensity (HT2) in cardiac magnetic resonance imaging (CMR), with the release of cardiac biomarkers, ventricular ejection, and clinical outcomes after revascularization.<br /><b>Methods and results</b><br />Patients with stable coronary artery disease with indication for revascularization were included. Biomarker levels (Troponin I [c-TnI] and creatine-kinase MB [CK-MB]) and T2-weighted and late gadolinium enhancement (LGE) images were obtained before and after the percutaneous or surgical revascularization procedures. The association of HT2 with the levels of biomarkers, with and without LGE, evolution of ejection fraction (LVEF), and 5-year clinical outcomes were assessed. A total of 196 patients were divided into two groups: Group 1 (HT2, 40) and Group 2 (no HT2, 156). Both peak c-TnI (8.9 and 1.6 ng/mL) and peak CK-MB values (44.7 and 12.1 ng/mL) were significantly higher in Group 1. Based on the presence of new LGE, patients were stratified into Groups A (no HT2/LGE, 149), B (HT2, 9), C (LGE, 7), and D (both HT2/LGE, 31). The peak c-TnI and CK-MB values were 1.5 and 12.0, 5.4 and 44.7, 5.0 and 18.3, and 9.8 and 42.8 ng/mL in Groups A, B, C, and D, respectively, and were significantly different. Average LVEF decreased 4.4% in Group 1 and increased 2.2% in Group 2 (p=0.057).<br /><b>Conclusion</b><br />ME after revascularization procedures was associated with increased release of cardiac necrosis biomarkers, and a trend towards a difference in LVEF, indicating a role of ME in cardiac injury after interventions.<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: 15 Jul 2023; epub ahead of print</small></div>

<div><h4>Neuroticism personality traits are linked to adverse cardiovascular phenotypes in the UK Biobank.</h4><i>Mahmood A, Simon J, Cooper J, Murphy T, ... Maurovich-Horvat P, Petersen SE</i><br /><b>Aims</b><br />To evaluate the relationship between neuroticism personality traits and cardiovascular magnetic resonance (CMR) measures of cardiac morphology and function, considering potential differential associations in men and women.<br /><b>Methods and results</b><br />The analysis includes 36,309 UK Biobank participants (average age= 63.9±7.7 years; 47.8% men) with CMR available and neuroticism score assessed by the 12-item Eysenck Personality Questionnaire-Revised Short Form. CMR scans were performed on 1.5 Tesla scanners (MAGNETOM Aera, Siemens Healthcare, Erlangen, Germany) according to pre-defined protocols and analysed using automated pipelines. We considered measures of left ventricular (LV) and right ventricular (RV) structure and function, and indicators of arterial compliance. Multivariable linear regression was used to estimate association of neuroticism score with individual CMR metrics, with adjustment for age, sex, obesity, deprivation, smoking, diabetes, hypertension, hypercholesterolaemia, alcohol use, exercise, and education. Higher neuroticism scores were associated with smaller LV and RV end-diastolic volumes, lower LV mass, greater concentricity (higher LV mass to volume ratio), and higher native T1. Greater neuroticism was also linked to poorer LV and RV function (lower stroke volumes) and greater arterial stiffness. In sex-stratified analyses, the relationships between neuroticism and LV stroke volume, concentricity, and arterial stiffness were attenuated in women. In men, association (with exception of native T1) remained robust.<br /><b>Conclusion</b><br />Greater tendency towards neuroticism personality traits is linked to smaller, poorer functioning ventricles with lower LV mass, higher myocardial fibrosis, and higher arterial stiffness. These relationships are independent of traditional vascular risk factors and are more robust in men than women.<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: 13 Jul 2023; epub ahead of print</small></div>

<div><h4>Imaging for Implementation of Heart Failure Guidelines.</h4><i>Nagueh SF, Nabi F, Chang SM, Al-Mallah M, Shah DJ, Bhimaraj A</i><br /><AbstractText>The classification of heart failure with implications for pharmacological therapeutic interventions rests on defining ejection fraction (EF) which is an imaging parameter. Imaging can provide diagnostic clues as to etiology of heart failure, it can also guide and help assess response to treatment. Echocardiography, cardiac magnetic resonance, cardiac computed tomography, positron emission tomography, and Tc 99 m pyrophosphate scanning provide information about the etiology of heart failure. Further, echocardiography plays the primary role in the evaluation of LV diastolic function and the estimation of LV filling pressures both at rest and with exercise during diastolic stress testing. Heart failure guidelines recognize 4 stages (A, B, C, and D) for heart failure. Cardiac imaging along with risk factors and clinical status is needed for identifying these stages. There are joint societal echocardiographic guidelines by ASE (American Association of Echocardiography) and EACVI (European Association of Cardiovascular Imaging) that are applicable to the imaging of heart failure patients. There are also separate guidelines for the evaluation of patients being considered for left ventricular assist device implantation, and for multimodality imaging of patients with heart failure and preserved EF. Cardiac catheterization is needed in patients whose hemodynamic status is uncertain after clinical and echocardiographic evaluation and to evaluate for coronary artery disease. Myocardial biopsy can identify the presence of myocarditis or specific infiltrative diseases when the findings by noninvasive imaging are not conclusive.</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: 07 Jul 2023; epub ahead of print</small></div>

<div><h4>Investigation of Factors Determining Hemodynamic Relevance of Leaflet Thrombosis after TAVI.</h4><i>Soschynski M, Hein M, Capilli F, Hagar MT, ... Bamberg F, Tobias K</i><br /><b>Aims</b><br />To determine the conditions under which early hypoattenuated leaflet thickening (HALT) after transcatheter aortic valve implantation (TAVI) becomes hemodynamically relevant.<br /><b>Methods and results</b><br />The study included 100 patients (age: 81.5 ± 5.5 years; female 63%), thereof 50 patients with HALT. After anonymization and randomization, blinded readers measured maximum thrombus thickness per prosthesis (MT_pr) and movement restriction (MR_pr) on ECG-gated whole heart cycle CTA. These measurements were compared with echocardiographic mean pressure gradient (mPG), its increase from baseline (ΔmPG) and doppler velocity index (DVI). Hemodynamic valve deterioration (HVD) was defined as mPG > 20mmHg. Age, body mass index, valve type, valve size, left ventricular ejection fraction and atrial fibrillation were considered as influencing factors.Multiple regression analysis revealed that only valve size (p = 0.001) and MT_pr (p = 0.02) had a significant influence on mPG. In an interaction model valve size moderated the effect of MT_pr on mPG significantly (p = 0.004). Subgroup analysis stratified by valve sizes showed a strong correlation between MT_pr and echocardiographic parameters for 23 mm valves (mPG: r = 0.57, ΔmPG: r = 0.68, DVI: r = 0.55, each with p < 0.001), but neither for 26 mm nor 29 mm valves (r < 0.2, p > 0.2 for all correlations). Six of seven prostheses with HVD had a 23 mm valve diameter, while one had 29 mm (p = 0.02).<br /><b>Conclusion</b><br />Early HALT rarely causes significant mPG increase. Our study shows that valve size is a key factor influencing the hemodynamic impact of HALT. In small valve sizes, mPG is more likely to increase. Our study is the first to offer in vivo evidence supporting previous in vitro findings on this topic.<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: 06 Jul 2023; epub ahead of print</small></div>

<div><h4>Prognostic value of left ventricular myocardial work indices in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.</h4><i>Wu HW, Fortuni F, Butcher SC, van der Kley F, ... Bax JJ, Ajmone Marsan N</i><br /><b>Aims</b><br />Left ventricular myocardial work (LVMW) is a novel echocardiographic-based method to assess left ventricular (LV) function using pressure-strain loops taking into account LV afterload. The aim of this study was to evaluate the prognostic value of LVMW indices in patients with severe AS undergoing transcatheter aortic valve replacement (TAVR).<br /><b>Methods and results</b><br />LV global work index (LV GWI), LV global constructive work (LV GCW), LV global wasted work (LV GWW) and LV global work efficiency (LV GWE) were calculated in 281 patients with severe AS (age 82, IQR 78-85 years, 52% male) prior to the TAVR procedure. LV systolic pressure was derived non-invasively by adding the mean aortic gradient to the brachial systolic pressure to adjust for afterload and calculate LVMW indices. Overall, the average LV GWI was 1872 ± 753 mmHg%, GCW 2240 ± 797 mmHg%, GWW 200 (IQR 127-306) mmHg% and GWE 89 (IQR 84-93)%. During a median follow-up of 52 (IQR 41-67) months, 64 patients died. While LV GWI was independently associated with all-cause mortality (HR per-tertile-increase 0.639; 95%CI 0.463-0.883; P = 0.007), LV GCW, GWW and GWE were not. When added to a basal model, LV GWI yielded a higher increase in predictivity compared to the LVEF as well as LV GLS and LV GCW, and also across the different hemodynamic categories (including low-flow low-gradient) of AS.<br /><b>Conclusion</b><br />LV GWI is independently associated with all-cause mortality in patients undergoing TAVR and has a higher prognostic value compared to both conventional and advanced parameters of LV systolic function.<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: 06 Jul 2023; epub ahead of print</small></div>

<div><h4>Women in Cardiovascular Imaging: A Call for Action to Address Ongoing Challenges.</h4><i>Joshi SS, Kadavath S, Mandoli GE, Gimelli A, ... Almeida AG, Julia G</i><br /><b>Aims</b><br />The EACVI Scientific Initiatives Committee and the EACVI women\'s taskforce conducted a global survey to evaluate the barriers faced by women in cardiovascular imaging (WICVi).<br /><b>Methods and results</b><br />In a prospective international survey, we assessed the barriers faced at work by WICVi. 314 participants from 53 countries responded. The majority were married (77%) and had children (68%), but most reported no flexibility in their work schedule during their pregnancy or after their maternity leave. More than half of the women reported experiencing unconscious bias (68%), verbal harassment (59%), conscious bias (51%), anxiety (70%), lack of motivation (60%), impostor syndrome (54%) and burnout (61%) at work. Furthermore, 1 in 5 respondents had experienced sexual harassment, although this was rarely reported formally.The majority reported availability of mentorship (73%), which was mostly rated as \'good\' or \'very good\'. Whilst more than two thirds of respondents (69%) now reported being well trained and qualified to take on leadership roles in their departments, only a third had been afforded that opportunity. Despite the issues highlighted by this survey,  > 80% of the participating WICVi would still choose cardiovascular imaging if they could restart their career.<br /><b>Conclusion</b><br />The survey has highlighted important issues faced by WICVi. Whilst progress has been made in areas such as mentorship and training, other issues including bullying, bias and sexual harassment are still widely prevalent requiring urgent action by the global cardiovascular imaging community to collectively address and resolve these challenges.<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: 06 Jul 2023; epub ahead of print</small></div>

<div><h4>Association Between Remnant Cholesterol and Progression of Bioprosthetic Valve Degeneration.</h4><i>Li Z, Zhang B, Salaun E, Côté N, ... Wu Y, Clavel MA</i><br /><b>Aims</b><br />Remnant cholesterol (RC) seems associated with native aortic stenosis. Bioprosthetic valve degeneration may share similar lipid-mediated pathways with aortic stenosis. We aimed to investigate the association of RC with the progression of bioprosthetic aortic valve degeneration and ensuing clinical outcomes.<br /><b>Methods and results</b><br />We enrolled 203 patients with a median of 7.0 years (interquartile range: 5.1-9.2) after surgical aortic valve replacement. RC concentration was dichotomized by the top RC tertile (23.7 mg/dl). At 3-year follow-up, 121 patients underwent follow-up visit for the assessment of annualized change in aortic valve calcium density (AVCd). RC levels showed a curvilinear relationship with an annualized progression rate of AVCd, with increased progression rates when RC >23.7 mg/dl (p = 0.008). There were 99 deaths and 46 aortic valve re-interventions in 133 patients during a median clinical follow-up of 8.8 (8.7-9.6) years. RC >23.7 mg/dl was independently associated with mortality or re-intervention (hazard ratio: 1.98; 95% confidence interval: 1.31-2.99; p = 0.001).<br /><b>Conclusions</b><br />Elevated RC is independently associated with faster progression of bioprosthetic valve degeneration and increased risk of all-cause mortality or aortic valve re-intervention.<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: 06 Jul 2023; epub ahead of print</small></div>

<div><h4>Multi-Modality Imaging in Aortic Stenosis an EACVI Clinical Consensus Document.</h4><i>Dweck MR, Loganath K, Bing R, Treibel TA, ... Otto CM, Pibarot P</i><br /><AbstractText>In this EACVI clinical scientific update, we will explore the current use of multi-modality imaging in the diagnosis, risk-stratification and follow-up of patients with aortic stenosis, with a particular focus on recent developments and future directions. Echocardiography is and will likely remain the key method of diagnosis and surveillance of aortic stenosis providing detailed assessments of valve haemodynamics and the cardiac remodelling response. CT is already widely used in the planning of transcutaneous aortic valve implantation. We anticipate its increased use as an anatomical adjudicator to clarify disease severity in patients with discordant echocardiographic measurements. CT calcium scoring is currently used for this purpose, however contrast computed tomography techniques are emerging that allow identification of both calcific and fibrotic valve thickening. Additionally, improved assessments of myocardial decompensation with echocardiography, cardiac magnetic resonance and computed tomography will become more commonplace in our routine assessment of aortic stenosis. Underpinning all of this will be widespread application of artificial intelligence. In combination we believe this new era of multi-modality imaging in aortic stenosis will improve the diagnosis, follow-up and timing of intervention in aortic stenosis as well as potentially accelerate the development of the novel pharmacological treatments required for this 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: 03 Jul 2023; epub ahead of print</small></div>

<div><h4>Coronary microevaginations characterize culprit plaques and their inflammatory microenvironment in a subtype of acute coronary syndrome with intact fibrous cap: results from the prospective translational OPTICO-ACS study.</h4><i>Seppelt C, Abdelwahed YS, Meteva D, Nelles G, ... Landmesser U, Leistner DM</i><br /><b>Aims</b><br />Coronary microevaginations (CME) represent an outward bulge of coronary plaques and have been introduced as a sign of adverse vascular remodeling following coronary device implantation. However, their role in atherosclerosis and plaque destabilization in the absence of coronary intervention is unknown. This study aimed to investigate CME as a novel feature of plaque vulnerability and to characterize its associated inflammatory cell-vessel-wall interactions.<br /><b>Methods and results</b><br />557 patients from the translational OPTICO-ACS study program underwent optical coherence tomography (OCT) imaging of culprit vessel and simultaneous immunophenotyping of the culprit lesion (CL). 258 CLs had ruptured- (RFC) and 100 had intact fibrous cap (IFC) ACS as an underlying pathophysiology. CME were significantly more frequent in CL as compared to non-CL (25% vs. 4%, p < 0.001) and were more frequently observed in lesions with IFC-ACS as compared to RFC-ACS (55.0% vs. 12.7%, p < 0.001). CME were particularly prevalent in IFC-ACS causing CLs independent of a coronary bifurcation (IFC-ICB) as compared to IFC-ACS with an association to a coronary bifurcation (IFC-ACB, 65.4% vs. 43.7%, p = 0.030). CME emerged as the strongest independent predictor of IFC-ICB (RR 3.36, 95%CI 1.67; 6.76, p = 0.001) by multivariable regression analysis. IFC-ICB demonstrated an enrichment of monocytes in both, culprit blood analysis (Culprit ratio: 1.1 ± 0.2 vs. 0.9 ± 0.2, p = 0.048) and aspirated culprit thrombi (326 ± 162 cells/mm2 vs. 96 ± 87 cells/mm2; p = 0.017), whilst IFC-ACB confirmed the accumulation of CD4+-T-Cells as recently described.<br /><b>Conclusion</b><br />This study provides novel evidence for a pathophysiological involvement of CME in the development of IFC-ACS and provides first evidence for a distinct pathophysiological pathway for IFC-ICB, driven by CME-derived flow disturbances and inflammatory activation involving the innate immune system.<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: 03 Jul 2023; epub ahead of print</small></div>

<div><h4>The role of imaging in the selection of patients for HFpEF therapy.</h4><i>Baron T, Gerovasileiou S, Flachskampf FA</i><br /><AbstractText>Heart failure with preserved ejection fraction (HFpEF) traditionally has been characterized as a form of heart failure without therapeutic options, in particular with a lack of response to the established therapies of heart failure with reduced ejection fraction (HFrEF). However, this is no longer true. Besides physical exercise, risk factor modification, aldosterone blocking agents, and sodium-glucose cotransporter 2 inhibitors, specific therapies are emerging for specific HFpEF etiologies, such as hypertrophic cardiomyopathy or cardiac amyloidosis. This development justifies increased efforts to arrive at specific diagnoses within the umbrella of HFpEF. Cardiac imaging plays by far the largest role in this effort and is discussed in the following review.</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: 03 Jul 2023; epub ahead of print</small></div>

<div><h4>Right ventricular to pulmonary artery coupling and outcome in patients with cardiac amyloidosis.</h4><i>Tomasoni D, Adamo M, Porcari A, Aimo A, ... Emdin M, Metra M</i><br /><b>Aims</b><br />To investigate the prognostic value of the right ventricle-to-pulmonary artery (RV-PA) coupling in patients with either transthyretin (ATTR) or immunoglobulin light-chain (AL) cardiac amyloidosis (CA).<br /><b>Methods and results</b><br />Overall, 283 patients with CA from 3 Italian high-volume centres were included (median age 76 years; 63% males; 53% with ATTR-CA, 47% with AL-CA). The RV-PA coupling was evaluated through tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio. The median value of TAPSE/PASP was 0.45 (0.33-0.63) mm/mmHg. Patients with a TAPSE/PASP ratio <0.45 were older, had lower systolic blood pressure, more severe symptoms, higher cardiac troponin and NT-proBNP levels, greater left ventricular (LV) thickness, and worse LV systolic and diastolic function. A TAPSE/PASP ratio <0.45 was independently associated with a higher risk of all-cause death or HF hospitalization (hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.32-2.96; p = 0.001) and all-cause death (HR 2.18; 95% CI, 1.31-3.62; p = 0.003). The TAPSE/PASP ratio reclassified the risk of both endpoints (net reclassification index 0.46 [95%CI 0.18-0.74], p = 0.001, and 0.49 [0.22-0.77] p < 0.001, respectively), while TAPSE or PASP alone did not (all p > 0.05). The prognostic impact of TAPSE/PASP ratio was significant both in AL-CA patients (HR for the composite endpoint 2.47, 95% CI 1.58-3.85; p < 0.001) and in ATTR-CA (HR 1.81, 95% CI 1.11-2.95; p = 0.017). Receiver operating characteristic curve showed that the optimal cut-off for predicting prognosis was 0.47 mm/mmHg.<br /><b>Conclusion</b><br />In patients with CA, RV-PA coupling predicted the risk of mortality or HF hospitalization. TAPSE/PASP ratio had a better performance than TAPSE or PASP in predicting prognosis.<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: 28 Jun 2023; epub ahead of print</small></div>

<div><h4>The Primary Cardiomyopathy of Systemic Sclerosis on Cardiovascular Magnetic Resonance Imaging.</h4><i>Chhikara S, Kanda A, Ogugua FM, Rouf R, ... Molitor JA, Shenoy C</i><br /><b>Aims</b><br />Cardiac disease in systemic sclerosis (SSc) may be primary or secondary to other disease manifestations of SSc. The prevalence of the primary cardiomyopathy of SSc is unknown. Cardiovascular magnetic resonance imaging (CMR) can help accurately determine the presence and cause of cardiomyopathy. We aimed to investigate the prevalence, the CMR features, and the prognostic implications of the primary cardiomyopathy of SSc.<br /><b>Methods and results</b><br />We conducted a retrospective cohort study of consecutive patients with SSc who had a clinical CMR for suspected cardiac involvement. We identified the prevalence, the CMR features of the primary cardiomyopathy of SSc, and its association with the long-term incidence of death or major adverse cardiac events (MACE): heart failure hospitalization, ventricular assist device implantation, heart transplantation, and sustained ventricular tachycardia. Of 130 patients with SSc, 80% were women, and the median age was 58 years. On CMR, 22% had an abnormal left ventricular ejection fraction (LVEF), and 40% had late gadolinium enhancement (LGE). The prevalence of the primary cardiomyopathy of SSc was 21%. A third of these patients had a distinct LGE phenotype. Over a median follow-up of 3.6 years after the CMR, patients with the primary cardiomyopathy of SSc had a greater incidence of death or MACE (adjusted hazard ratio 2.01; 95% confidence interval 1.03-3.92; p=0.041).<br /><b>Conclusion</b><br />The prevalence of the primary cardiomyopathy of SSc was 21%, with a third demonstrating a distinct LGE phenotype. The primary cardiomyopathy of SSc was independently associated with a greater long-term incidence of death or MACE.<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 Jun 2023; epub ahead of print</small></div>

<div><h4>Layer myocardial strain is the most heritable echocardiographic trait.</h4><i>Huttin O, Xhaard C, Dandine-Roulland C, Le Floch E, ... Rossignol P, Girerd N</i><br /><b>Background</b><br />Myocardial deformation assessed by strain analysis represents a significant advancement in our assessment of cardiac mechanics. However, whether this variable is genetically heritable or whether all/most of its variability is related to environmental factors is currently unknown.We sought to determine the heritability of echocardiographically determined cardiac mechanics indices in a population setting.<br /><b>Methods</b><br />A total of 1357 initially healthy subjects (women 51.6%; 48.2 ± 14.1 years) were included in this study from 20 years follow-up after the 4th visit of the longitudinal familial STANISLAS cohort (Lorraine, France). Data were acquired using state-of-the-art cardiac ultrasound equipment, using acquisition and measurement protocols recommended by the EACVI/ASE/Industry Task Force. Layer-specific global longitudinal strain (GLS) and global circumferential strain (GCS) (full-wall, subendocardial and subepicardial) and conventional structural and functional cardiac parameters and their potential heritability were assessed using restricted maximum likelihood analysis, with genetic relatedness matrix calculated from genome-wide association data.<br /><b>Results</b><br />Indices of longitudinal/circumferential myocardial function and left ventricular (LV) ejection fraction had low heritability (ranging from 10 to 20%). Diastolic and standard LV function parameters had moderate heritability (ranging from 20 to 30%) except for end-systolic and end-diastolic volumes (respectively 30 and 45%). In contrast, GLSEndo/GLSEpi ratio had a high level of heritability (65%). Except for GLSendo/GLSepi ratio, a large percentage of variance remained unexplained (greater than 50%).<br /><b>Conclusions</b><br />In our population cohort, GLSendo/GLSepi ratio had a high level of heritability whereas other classical and mechanical LV function parameters did not. Given the increasing recognition of GLSendo/GLSepi ratio as an early/sensitive imaging biomarker of systolic dysfunction, our results suggest the possible existence of individual genetic predispositions to myocardial decline.<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 Jun 2023; epub ahead of print</small></div>

<div><h4>Influence of cusp morphology and sex on quantitative valve composition in severe aortic stenosis.</h4><i>Patel KP, Lin A, Kumar N, Esposito G, ... Dweck MR, Dey D</i><br /><b>Aims</b><br />Aortic stenosis is characterized by fibrosis and calcification of the valve, with a higher proportion of fibrosis observed in women. Stenotic bicuspid aortic valves progress more rapidly than tricuspid valves which may also influence the relative composition of the valve.We aimed to investigate the influence of cusp morphology on quantitative aortic valve composition quantified from contrast-enhanced computed tomography angiography in severe aortic stenosis.<br /><b>Methods and results</b><br />Patients undergoing transcatheter aortic valve implantation with bicuspid and tricuspid valves were propensity matched 1:1 by age, sex, and comorbidities. Computed tomography angiograms were analyzed using semi-automated software to quantify fibrotic and calcific scores (volume/valve annular area) and the fibro-calcific ratio (fibrotic score/calcific score).The study population (n = 140) was elderly (76 ± 10 years, 62% male) and had a peak aortic jet velocity of 4.1 ± 0.7 m/s. Compared to those with tricuspid valves (n = 70), patients with bicuspid valves (n = 70) had higher fibrotic scores (204 [interquartile range 118-267] versus 144[99-208] mm3/cm2, p = 0.006) with similar calcific scores (p = 0.614). Women had greater fibrotic scores than men in bicuspid (224[181-307] versus 169[109- 247] mm3/cm2; p = 0.042) but not tricuspid valves (p = 0.232). Men had greater calcific scores than women in both bicuspid (203[124-355] versus 130[70-182] mm3/cm2; p = 0.008) and tricuspid (177[136-249] versus 100[62-150] mm3/cm2; p = 0.004) valves. Among both valve types, women had greater fibro-calcific ratio compared to men (tricuspid 1.86[0.94-2.56] versus 0.86[0.54-1.24], p = 0.001 and bicuspid 1.78[1.21-2.90] versus 0.74[0.44-1.53], p = 0.001).<br /><b>Conclusions</b><br />In severe aortic stenosis, bicuspid valves have proportionately more fibrosis than tricuspid valves, especially in women.<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 Jun 2023; epub ahead of print</small></div>

<div><h4>Coronary Angiography-Derived Index of Microcirculatory Resistance and Evolution of Infarct Pathology after STEMI.</h4><i>Wang X, Guo Q, Guo R, Guo Y, ... Fearon WF, Nie S</i><br /><b>Aim</b><br />This study sought to evaluate the association of coronary angiography-derived index of microcirculatory resistance (angio-IMR) measured after primary percutaneous coronary intervention (PPCI) with evolution of infarct pathology during 3-month follow-up after ST-segment-elevation myocardial infarction (STEMI).<br /><b>Methods and results</b><br />Patients with STEMI undergoing PPCI were prospectively enrolled between October 2019 and August 2021. Angio-IMR was calculated using computational flow and pressure simulation immediately after PPCI. Cardiac magnetic resonance (CMR) imaging was performed at a median of 3.6 days and 3 months. A total of 286 STEMI patients (mean age 57.8 years, 84.3% men) with both angio-IMR and CMR at baseline were included. High angio-IMR (>40 U) occurred in 84 patients (29.4%) patients. Patients with angio-IMR >40 U had higher prevalence and extent of MVO. An angio-IMR >40 U was a multivariable predictor of infarct size with 3-fold higher risk of final infarct size >25% (adjusted OR 3.00, 95% CI 1.23-7.32, p = 0.016). Post-procedure angio-IMR >40 U significantly predicted presence (adjusted OR 5.52, 95% CI 1.65-18.51, p = 0.006) and extent (beta coefficient 0.27, 95% CI 0.01-0.53, p = 0.041) of myocardial iron at follow-up. Compared with patients with angio-IMR ≤40 U, those with angio-IMR >40 U had less regression of infarct size and less resolution of myocardial iron at follow-up.<br /><b>Conclusions</b><br />Angio-IMR immediately post PPCI showed a significant association with extent and evolution of infarct pathology. An angio-IMR >40 U indicated extensive microvascular damage with less regression of infarct size and more persistent iron at follow-up.<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: 15 Jun 2023; epub ahead of print</small></div>

<div><h4>Multimodality imaging in marantic endocarditis associated with cancer: a multicentric cohort study.</h4><i>Deharo F, Arregle F, Bohbot Y, Tribouilloy C, ... Gouriet F, Habib G</i><br /><b>Aims</b><br />We aimed to assess the role of multimodality imaging (MMI) in the diagnosis of marantic endocarditis (ME) associated with cancers and to describe clinical characteristics, management, and outcome of these patients.<br /><b>Methods and results</b><br />In a retrospective multicentric study including four tertiary centers for treatment of endocarditis in France and Belgium, patients with a diagnosis of ME were included. Demographic, MMI (echocardiography, computed tomography (CT) and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F -FDG PET/CT) and management data were collected. Long-term mortality was analyzed. Between November 2011 and August 2021, 47 patients with a diagnosis of ME were included. Mean age was 65 +/- 11 years. ME occurred in 43 cases (91%) on native valves. Vegetations were detected by echocardiography in all cases and in 12 cases (26%) by CT. No patient had an increased cardiac 18F -FDG valve uptake. The most common cardiac valve involved was aortic (34 cases, 73%). 22 patients (46%) had a known cancer before ME and 25 cases (54%) were diagnosed thanks to multimodality imaging. 18-FDG PET/CT was performed in 30 patients (64%) and allowed a new diagnosis of cancer in 14 patients (30%). Systemic embolism was frequent (40 patients, 85% of cases). 41 patients (87%) were treated medically with anticoagulation therapy. One year mortality was 55% (26 patients).<br /><b>Conclusions</b><br />ME remains associated with high risk of complications and death.<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 Jun 2023; epub ahead of print</small></div>

<div><h4>Redefining cardiac damage staging in aortic stenosis: the value of GLS and RVAc.</h4><i>Gutierrez-Ortiz E, Olmos C, Carrión-Sanchez I, Jiménez P, ... de Agustín A, Islas F</i><br /><b>Aims</b><br />cardiac damage staging has been postulated as a prognostic tool in patients undergoing transcatheter aortic valve replacement (TAVR). The aims of our study are 1) to validate cardiac damage staging systems previously described to stratify patients with aortic stenosis (AS); 2) to identify independent risk factors for 1-year mortality in patients with severe AS undergoing TAVR and 3) to develop a novel staging model and compare its predictive performance to that of the abovementioned.<br /><b>Methods and results</b><br />patients undergoing TAVR from 2017 to 2021 were included in a single-center prospective registry. Transthoracic echocardiography was performed in all patients before TAVR. Logistic and Cox\'s regression analysis were used to identify predictors of 1-year all-cause mortality. In addition, patients were classified based on previously published cardiac damage staging systems, and the predictive performance of the different scores was measured.496 patients (mean age 82.1±5.9 years, 53% female) were included. Mitral regurgitation (MR), left ventricle global longitudinal strain (LV-GLS) and right ventricular-arterial coupling (RVAc) were independent predictors of all-cause 1-year mortality. A new classification system with four different stages was developed using LV-GLS, MR, and RVAc. The area under the ROC curve was 0.66 (95% confidence interval 0.63-0.76), and its predictive performance was superior compared to the previously published systems (p< 0.001).<br /><b>Conclusion</b><br />Cardiac damage staging might have an important role in patients\' selection and better timing for TAVR. A model that includes LV-GLS MR, and RVAc may help to improve prognostic stratification and contribute to better selection of patients undergoing TAVR.<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 Jun 2023; epub ahead of print</small></div>

<div><h4>Characterizing the hypertensive cardiovascular phenotype in the UK Biobank.</h4><i>Elghazaly H, McCracken C, Szabo L, Malcolmson J, ... Petersen SE, Raisi-Estabragh Z</i><br /><b>Aims</b><br />To describe hypertension-related cardiovascular magnetic resonance (CMR) phenotypes in the UK Biobank considering variations across patient populations.<br /><b>Methods and results</b><br />We studied 39 095 (51.5% women, mean age: 63.9 ± 7.7 years, 38.6% hypertensive) participants with CMR data available. Hypertension status was ascertained through health record linkage. Associations between hypertension and CMR metrics were estimated using multivariable linear regression adjusting for major vascular risk factors. Stratified analyses were performed by sex, ethnicity, time since hypertension diagnosis, and blood pressure (BP) control. Results are standardized beta coefficients, 95% confidence intervals, and P-values corrected for multiple testing. Hypertension was associated with concentric left ventricular (LV) hypertrophy (increased LV mass, wall thickness, concentricity index), poorer LV function (lower global function index, worse global longitudinal strain), larger left atrial (LA) volumes, lower LA ejection fraction, and lower aortic distensibility. Hypertension was linked to significantly lower myocardial native T1 and increased LV ejection fraction. Women had greater hypertension-related reduction in aortic compliance than men. The degree of hypertension-related LV hypertrophy was greatest in Black ethnicities. Increasing time since diagnosis of hypertension was linked to adverse remodelling. Hypertension-related remodelling was substantially attenuated in hypertensives with good BP control.<br /><b>Conclusion</b><br />Hypertension was associated with concentric LV hypertrophy, reduced LV function, dilated poorer functioning LA, and reduced aortic compliance. Whilst the overall pattern of remodelling was consistent across populations, women had greater hypertension-related reduction in aortic compliance and Black ethnicities showed the greatest LV mass increase. Importantly, adverse cardiovascular remodelling was markedly attenuated in hypertensives with good BP control.<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: 13 Jun 2023; epub ahead of print</small></div>

<div><h4>Three-dimensional echocardiographic left ventricular strain analysis in Fabry disease: correlation with heart failure severity, myocardial scar, and impact on long-term prognosis.</h4><i>Marek J, Chocholová B, Rob D, Paleček T, ... Dostálová G, Linhart A</i><br /><b>Aims</b><br />Fabry disease (FD) is a multisystemic lysosomal storage disorder caused by a defect in the alpha-galactosidase A gene that manifests as a phenocopy of hypertrophic cardiomyopathy. We assessed the echocardiographic 3D left ventricular (LV) strain of patients with FD in relation to heart failure severity using natriuretic peptides, the presence of a cardiovascular magnetic resonance (CMR) late gadolinium enhancement scar, and long-term prognosis.<br /><b>Methods and results</b><br />3D echocardiography was feasible in 75/99 patients with FD [aged 47 ± 14 years, 44% males, LV ejection fraction (EF) 65 ± 6% and 51% with hypertrophy or concentric remodelling of the LV]. Long-term prognosis (death, heart failure decompensation, or cardiovascular hospitalization) was assessed over a median follow-up of 3.1 years. A stronger correlation was observed for N-terminal pro-brain natriuretic peptide levels with 3D LV global longitudinal strain (GLS, r = -0.49, P < 0.0001) than with 3D LV global circumferential strain (GCS, r = -0.38, P < 0.001) or 3D LVEF (r = -0.25, P = 0.036). Individuals with posterolateral scar on CMR had lower posterolateral 3D circumferential strain (CS; P = 0.009). 3D LV-GLS was associated with long-term prognosis [adjusted hazard ratio 0.85 (confidence interval 0.75-0.95), P = 0.004], while 3D LV-GCS and 3D LVEF were not (P = 0.284 and P = 0.324).<br /><b>Conclusion</b><br />3D LV-GLS is associated with both heart failure severity measured by natriuretic peptide levels and long-term prognosis. Decreased posterolateral 3D CS reflects typical posterolateral scarring in FD. Where feasible, 3D-strain echocardiography can be used for a comprehensive mechanical assessment of the LV in patients with FD.<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: 13 Jun 2023; epub ahead of print</small></div>

<div><h4>Absence of Infective Endocarditis Relapse when End-of-treatment FDG-PET/CT is Negative.</h4><i>Régis C, Thy M, Mahida B, Deconinck L, ... Duval X, Rouzet F</i><br /><b>Aims</b><br />In non-operated infective endocarditis (IE), relapse may impair the outcome of the disease. The aim of the study was to evaluate the relationship between end-of-treatment (EOT) FDG-PET/CT results and relapse in non-operated IE either on native or prosthetic valve.<br /><b>Methods and results</b><br />We included 62 patients who underwent an EOT FDG-PET/CT for non-operated IE performed between 30 and 180 days of antibiotic therapy initiation. Qualitative valve assessment categorized initial and EOT FDG-PET/CT as negative or positive. Quantitative analyses were also conducted. Clinical data from medical charts were collected, including Endocarditis Team decision for IE diagnosis and relapse. Forty-one (66%) patients were male with a median age of 68 years [57; 80] and 42 (68%) had prosthetic valve IE. EOT FDG-PET/CT was negative in 29 and positive in 33 patients. The proportion of positive scans decreased significantly compared with initial FDG-PET/CT (53% vs. 77% respectively, p < 0.0001). All relapses (n = 7, 11%) occurred in patients with a positive EOT FDG-PET/CT with a median delay after EOT FDG-PET/CT of 10 days [0; 45]. The relapse rate was significantly lower in negative (0/29) than in positive (7/33) EOT FDG-PET/CT (p = 0.01).<br /><b>Conclusion</b><br />In this series of 62 patients with non-operated IE who underwent EOT FDG-PET/CT, those with a negative scan (almost half of the study population) did not develop IE relapse after a median follow-up of 10 months. These findings need to be confirmed by prospective and larger studies.<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: 12 Jun 2023; epub ahead of print</small></div>

<div><h4>Phenotyping heart failure by nuclear imaging of myocardial perfusion, metabolism, and molecular targets.</h4><i>Saraste A, Knuuti J, Bengel F</i><br /><AbstractText>Nuclear imaging techniques can detect and quantify pathophysiological processes underlying heart failure, complementing evaluation of cardiac structure and function with other imaging modalities. Combined imaging of myocardial perfusion and metabolism can identify left ventricle dysfunction caused by myocardial ischemia that may be reversible after revascularization in the presence of viable myocardium. High sensitivity of nuclear imaging to detect targeted tracers has enabled assessment of various cellular and subcellular mechanisms of heart failure. Nuclear imaging of active inflammation and amyloid deposition is incorporated into clinical management algorithms of cardiac sarcoidosis and amyloidosis. Innervation imaging has well documented prognostic value with respect to heart failure progression and arrhythmias. Emerging tracers specific for inflammation and myocardial fibrotic activity are in earlier stages of development, but have demonstrated potential value in early characterization of the response to myocardial injury and prediction of adverse left ventricular remodeling. Early detection of disease activity is a key for transition from broad medical treatment of clinically overt heart failure towards a personalized approach aimed at supporting repair and preventing progressive failure. This review outlines the current status of nuclear imaging in phenotyping heart failure, and combines it with discussion on novel developments.</AbstractText><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 Jun 2023; epub ahead of print</small></div>

<div><h4>Diagnostic performance of clinical likelihood models of obstructive coronary artery disease to predict myocardial perfusion defects.</h4><i>Rasmussen LD, Albertsen LEB, Nissen L, Ejlersen JA, ... Bøttcher M, Winther S</i><br /><b>Aims</b><br />Clinical likelihood (CL) models are designed based on a reference of coronary stenosis in patients with suspected obstructive coronary artery disease (CAD). However, a reference standard of a myocardial perfusion defects (MPD) could be more appropriate.We aimed to investigate the ability of the 2019 European Society of Cardiology pre-test probability (ESC-PTP), the risk factor-weighted (RF-CL) and coronary artery calcium score-weighted (CACS-CL) models to diagnose MPDs.<br /><b>Methods and results</b><br />Symptomatic stable de novo chest pain patients (n = 3374) underwent coronary computed tomography angiography (CTA) and subsequent myocardial perfusion imaging by single photon emission tomography (SPECT), positron emission tomography (PET) or cardiac magnetic resonance (CMR). For all modalities, MPD was defined as coronary CTA with suspected stenosis and stress-perfusion abnormality in ≥2 segments. The ESC-PTP was calculated based on age, sex and symptom typicality, and the RF-CL and CACS-CL additionally included a number of risk factors and CACS.In total, 219/3374 (6.5%) patients had a MPD. Both the RF-CL and CACS-CL classified substantially more patients to low CL (<5%) of obstructive CAD compared to the ESC-PTP (32.5% and 54.1% vs. 12.0%, p < 0.001) with preserved low prevalences of MPD (<2% for all models). Compared to the ESC-PTP (AUC 0.74 (0.71-0.78), the discrimination of having a MPD was higher for the CACS-CL (AUC 0.88 (0.86-0.91), p < 0.001) while similar for the RF-CL model (AUC 0.73 (0.70-0.76), p = 0.32).<br /><b>Conclusions</b><br />Compared to basic CL models, the RF-CL and CACS-CL models improve down-classification of patients to a very low-risk group with low prevalence of MPD.<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: 07 Jun 2023; epub ahead of print</small></div>

<div><h4>Multimodality imaging for patient selection, procedural guidance, and follow-up of transcatheter interventions for structural heart disease: a consensus document of the EACVI Task Force on Interventional Cardiovascular Imaging: part 1: access routes, transcatheter aortic valve implantation, and transcatheter mitral valve interventions.</h4><i>Agricola E, Ancona F, Bartel T, Brochet E, ... Cosyns B, Donal E</i><br /><AbstractText>Transcatheter therapies for the treatment of structural heart diseases (SHD) have expanded dramatically over the last years, thanks to the developments and improvements of devices and imaging techniques, along with the increasing expertise of operators. Imaging, in particular echocardiography, is pivotal during patient selection, procedural monitoring, and follow-up. The imaging assessment of patients undergoing transcatheter interventions places demands on imagers that differ from those of the routine evaluation of patients with SHD, and there is a need for specific expertise for those working in the cath lab. In the context of the current rapid developments and growing use of SHD therapies, this document intends to update the previous consensus document and address new advancements in interventional imaging for access routes and treatment of patients with aortic stenosis and regurgitation, and mitral stenosis and regurgitation.</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: 07 Jun 2023; epub ahead of print</small></div>

<div><h4>Phenotyping heart failure by cardiac magnetic resonance imaging of cardiac macro- and microscopic structure: state of the art review.</h4><i>Pan J, Ng SM, Neubauer S, Rider OJ</i><br /><AbstractText>Heart failure demographics have evolved in past decades with the development of improved diagnostics, therapies and prevention. Cardiac magnetic resonance (CMR) has developed in a similar timeframe to become the gold-standard non-invasive imaging modality for characterising diseases causing heart failure. CMR techniques to assess cardiac morphology and function have progressed since their first use in the 1980s. Increasingly efficient acquisition protocols generate high spatial and temporal resolution images in shorter time frames. This has enabled new methods of characterising cardiac systolic and diastolic function such as strain analysis, exercise real-time (RT) cine imaging and four-dimensional (4D) flow. A key strength of CMR is its ability to non-invasively interrogate the myocardial tissue composition. Gadolinium contrast agents revolutionised non-invasive cardiac imaging with the late gadolinium enhancement (LGE) technique. Further advances enabled quantitative parametric mapping to increase sensitivity at detecting diffuse pathology. Novel methods such as diffusion tensor imaging (DTI) and artificial intelligence-enhanced image generation are on the horizon. MRS provides a window into the molecular environment of the myocardium. Specifically, phosphorus (31P) spectroscopy can inform the status of cardiac energetics in health and disease. Proton (1H) spectroscopy can complement this by measuring creatine and intramyocardial lipids. Hyperpolarised carbon (13C) spectroscopy is a novel method that could further our understanding of dynamic cardiac metabolism. CMR of other organs such as the lungs may add further depth into phenotypes of heart failure. The vast capabilities of CMR need to be deployed and interpreted in context of current heart failure challenges.</AbstractText><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: 02 Jun 2023; epub ahead of print</small></div>

<div><h4>Three-dimensional transoesophageal echocardiography: how to use and when to use-a clinical consensus statement from the European Association of Cardiovascular Imaging of the European Society of Cardiology.</h4><i>Faletra FF, Agricola E, Flachskampf FA, Hahn R, ... Keenan N, Stankovic I</i><br /><AbstractText>Three-dimensional transoesophageal echocardiography (3D TOE) has been rapidly developed in the last 15 years. Currently, 3D TOE is particularly useful as an additional imaging modality for the cardiac echocardiographers in the echo-lab, for cardiac interventionalists as a tool to guide complex catheter-based procedures cardiac, for surgeons to plan surgical strategies, and for cardiac anaesthesiologists and/or cardiologists, to assess intra-operative results. The authors of this document believe that acquiring 3D data set should become a \'standard part\' of the TOE examination. This document provides (i) a basic understanding of the physic of 3D TOE technology which enables the echocardiographer to obtain new skills necessary to acquire, manipulate, and interpret 3D data sets, (ii) a description of valvular pathologies, and (iii) a description of non-valvular pathologies in which 3D TOE has shown to be a diagnostic tool particularly valuable. This document has a new format: instead of figures randomly positioned through the text, it has been organized in tables which include figures. We believe that this arrangement makes easier the lecture by clinical cardiologists and practising echocardiographers.</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: 01 Jun 2023; epub ahead of print</small></div>

<div><h4>Association of left ventricular strain-volume loop characteristics with adverse events in patients with heart failure with preserved ejection fraction.</h4><i>Kerstens TP, Weerts J, van Dijk APJ, Weijers G, ... van Empel VPM, Thijssen DHJ</i><br /><b>Aims</b><br />Patients with heart failure with preserved ejection fraction (HFpEF) are characterized by impaired diastolic function. Left ventricular (LV) strain-volume loops (SVL) represent the relation between strain and volume during the cardiac cycle and provide insight into systolic and diastolic function characteristics. In this study, we examined the association of SVL parameters and adverse events in HFpEF.<br /><b>Methods and results</b><br />In 235 patients diagnosed with HFpEF, LV-SVL were constructed based on echocardiography images. The endpoint was a composite of all-cause mortality and Heart Failure (HF)-related hospitalization, which was extracted from electronic medical records. Cox-regression analysis was used to assess the association of SVL parameters and the composite endpoint, while adjusting for age, sex, and NYHA class. HFpEF patients (72.3% female) were 75.8 ± 6.9 years old, had a BMI of 29.9 ± 5.4 kg/m2, and a left ventricular ejection fraction of 60.3 ± 7.0%. Across 2.9 years (1.8-4.1) of follow-up, 73 Patients (31%) experienced an event. Early diastolic slope was significantly associated with adverse events [second quartile vs. first quartile: adjusted hazards ratio (HR) 0.42 (95%CI 0.20-0.88)] after adjusting for age, sex, and NYHA class. The association between LV peak strain and adverse events disappeared upon correction for potential confounders [adjusted HR 1.02 (95% CI 0.96-1.08)].<br /><b>Conclusion</b><br />Early diastolic slope, representing the relationship between changes in LV volume and strain during early diastole, but not other SVL-parameters, was associated with adverse events in patients with HFpEF during 2.9 years of follow-up.<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: 01 Jun 2023; epub ahead of print</small></div>

<div><h4>Coronary microvascular health in symptomatic patients with prior COVID-19 infection: an updated analysis.</h4><i>Ahmed AI, Al Rifai M, Alahdab F, Saad JM, ... Zoghbi WA, Al-Mallah MH</i><br /><b>Aims</b><br />Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with endothelial dysfunction. We aimed to determine the effects of prior coronavirus disease 2019 (COVID-19) on the coronary microvasculature accounting for time from COVID-19, disease severity, SARS-CoV-2 variants, and in subgroups of patients with diabetes and those with no known coronary artery disease.<br /><b>Methods and results</b><br />Cases consisted of patients with previous COVID-19 who had clinically indicated positron emission tomography (PET) imaging and were matched 1:3 on clinical and cardiovascular risk factors to controls having no prior infection. Myocardial flow reserve (MFR) was calculated as the ratio of stress to rest myocardial blood flow (MBF) in mL/min/g of the left ventricle. Comparisons between cases and controls were made for the odds and prevalence of impaired MFR (MFR < 2). We included 271 cases matched to 815 controls (mean ± SD age 65 ± 12 years, 52% men). The median (inter-quartile range) number of days between COVID-19 infection and PET imaging was 174 (58-338) days. Patients with prior COVID-19 had a statistically significant higher odds of MFR <2 (adjusted odds ratio 3.1, 95% confidence interval 2.8-4.25 P < 0.001). Results were similar in clinically meaningful subgroups. The proportion of cases with MFR <2 peaked 6-9 months from imaging with a statistically non-significant downtrend afterwards and was comparable across SARS-CoV-2 variants but increased with increasing severity of infection.<br /><b>Conclusion</b><br />The prevalence of impaired MFR is similar by duration of time from infection up to 1 year and SARS-CoV-2 variants, but significantly differs by severity of infection.<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 May 2023; epub ahead of print</small></div>

<div><h4>Prognostic implications of left ventricular torsion measured by feature-tracking cardiac magnetic resonance in patients with ST-elevation myocardial infarction.</h4><i>Lai W, Chen-Xu Z, Jian-Xun D, Jie H, ... Heng G, Jun P</i><br /><b>Aims</b><br />The prognostic implication of left ventricular (LV) torsion on ST-elevation myocardial infarction (STEMI) is unclear.<br /><b>Methods and results</b><br />We analysed cardiovascular magnetic resonance (CMR) findings of 420 patients from a registry study (NCT03768453). These patients received CMR examination within 1 week after timely primary percutaneous coronary intervention. LV torsion and other CMR indexes were measured. Compared with healthy control subjects, STEMI significantly decreased patients\' LV torsion (1.04 vs. 1.63°/cm, P < 0.001). During follow-up (median, 52 months), the reduction of LV torsion was greater in patients with than without composite major adverse cardiac and cerebrovascular events (MACCEs, 0.79 vs. 1.08°/cm, P < 0.001). The risk of MACCEs would increase to 1.125- or 1.092-fold, and the risk of 1-year LV remodelling would increase to 1.110- or 1.082-fold for every 0.1°/cm reduction in LV torsion after adjustment for clinical or CMR parameters respectively. When divided dichotomously, patients with LV torsion≤ 0.802°/cm had significantly higher risk of MACCEs (40.2 vs. 12.3%, P < 0.001) and more remarkable LV remodelling (46.1 vs. 11.9%, P < 0.001) than patients with better LV torsion. The addition of LV torsion to conventional prognostic factors such as the LV ejection fraction and infarction size led to a better risk classification model of patients for both MACCEs and LV remodelling. Finally, tobacco use, worse post-PCI flow, and greater microvascular obstruction size were presumptive risk factors for reduced LV torsion.<br /><b>Conclusion</b><br />LV torsion measured by CMR is closely associated with the prognosis of STEMI and would be a promising indicator to improve patients\' risk stratification.<br /><b>Clinical trial registration</b><br />Clinicaltrials.gov, NCT03768453.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 31 May 2023; 24:785-795</small></div>

<div><h4>Importance of plaque volume and composition for the prediction of myocardial ischaemia using sequential coronary computed tomography angiography/positron emission tomography imaging.</h4><i>Wang X, van den Hoogen IJ, Butcher SC, Kuneman JH, ... Knuuti J, Bax JJ</i><br /><b>Aims</b><br />Coronary atherosclerosis with a large necrotic core has been postulated to reduce the vasodilatory capacity of vascular tissue. In the present analysis, we explored whether total plaque volume and necrotic core volume on coronary computed tomography angiography (CCTA) are independently associated with myocardial ischaemia on positron emission tomography (PET).<br /><b>Methods and results</b><br />From a registry of symptomatic patients with suspected coronary artery disease and clinically indicated CCTA with sequential [15O]H2O PET myocardial perfusion imaging, we quantitatively measured diameter stenosis, total and compositional plaque volumes on CCTA. Primary endpoint was myocardial ischaemia on PET, defined as an absolute stress myocardial blood flow ≤2.4 mL/g/min in ≥1 segment. Multivariable prediction models for myocardial ischaemia were consecutively created using logistic regression analysis (stenosis model: diameter stenosis ≥50%; plaque volume model: +total plaque volume; plaque composition model: +necrotic core volume). A total of 493 patients (mean age 63 ± 8 years, 54% men) underwent sequential CCTA/PET imaging. In 153 (31%) patients, myocardial ischaemia was detected on PET. Diameter stenosis ≥50% (P < 0.001) and necrotic core volume (P = 0.029) were independently associated with myocardial ischaemia, while total plaque volume showed borderline significance (P = 0.052). The plaque composition model (χ2 = 169) provided incremental value for the prediction of ischaemia when compared with the stenosis model (χ2 = 138, P < 0.001) and plaque volume model (χ2 = 164, P = 0.021).<br /><b>Conclusion</b><br />The volume of necrotic core on CCTA independently and incrementally predicts myocardial ischaemia on PET, beyond diameter stenosis alone.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 31 May 2023; 24:776-784</small></div>

<div><h4>Incidence, causes, correlates, and outcome of bioprosthetic valve dysfunction and failure following transcatheter aortic valve implantation.</h4><i>Nitsche C, Koschutnik M, Donà C, Mutschlechner D, ... Hengstenberg C, Mascherbauer J</i><br /><b>Aims</b><br />Bioprosthetic valve dysfunction (BVD) is a major concern regarding transcatheter aortic valve implantation (TAVI) durability. We aimed to assess incidence, correlates, causes, and outcome of early to mid-term BVD after TAVI in relation to patient\'s life expectancy.<br /><b>Methods and results</b><br />Consecutive TAVI recipients (2007-20) with a follow-up ≥1 year were prospectively included. BVD and bioprosthetic valve failure (BVF) were assessed according to Valve-Academic-Research-Consortium-3. BVD/BVF and all-cause death served as endpoints. Average life expectancy was calculated from National Open Health Data and patients were stratified according to tertiles (1st: <6.85 years, 2nd: 6.85-9.7 years, 3rd: >9.7 years). Of 1047 patients (81.6 ± 6.8 years old, EuroSCORE II 4.5 ± 2.5), ≥2 follow ups were available from 622 (serial echo cohort). After a median echo follow up of 12.2 months, incidence rates of BVD/BVF were 8.4% (95% confidence interval 6.7-10.3), and 3.5% (2.5-4.9) per valve-year, respectively, without differences between life expectancy tertiles. The incidence of BVD was two-fold higher within the first year of implant (9.9% per valve-year) vs. beyond (4.8% per valve-year). Valve-in-valve procedure and residual stenosis, but not age/life expectancy predisposed for BVD. BVD/BVF were independently associated with outcome for patients in the first [adjusted hazard ratio (AHR) 1.72 (1.06-2.88)/2.97 (1.72-6.22)] and second [AHR 1.96 (1.02-3.73)/2.31 (1.00-5.30)], but not the third tertile of life expectancy (P = n.s.).<br /><b>Conclusions</b><br />In this large prospective observational cohort, early to mid-term BVD after TAVI occurred at the same rate across the spectrum of life expectancy and was associated with increased mortality in patients with short but not in those with the longest life expectancy.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Cardiovasc Imaging: 31 May 2023; 24:796-806</small></div>

<div><h4>Impact of statins based on high-risk plaque features on coronary plaque progression in mild stenosis lesions: results from the PARADIGM study.</h4><i>Park HB, Arsanjani R, Sung JM, Heo R, ... Min JK, Chang HJ</i><br /><b>Aims</b><br />To investigate the impact of statins on plaque progression according to high-risk coronary atherosclerotic plaque (HRP) features and to identify predictive factors for rapid plaque progression in mild coronary artery disease (CAD) using serial coronary computed tomography angiography (CCTA).<br /><b>Methods and results</b><br />We analyzed mild stenosis (25-49%) CAD, totaling 1432 lesions from 613 patients (mean age, 62.2 years, 63.9% male) and who underwent serial CCTA at a ≥2 year inter-scan interval using the Progression of AtheRosclerotic PlAque DetermIned by Computed TomoGraphic Angiography Imaging (NCT02803411) registry. The median inter-scan period was 3.5 ± 1.4 years; plaques were quantitatively assessed for annualized percent atheroma volume (PAV) and compositional plaque volume changes according to HRP features, and the rapid plaque progression was defined by the ≥90th percentile annual PAV. In mild stenotic lesions with ≥2 HRPs, statin therapy showed a 37% reduction in annual PAV (0.97 ± 2.02 vs. 1.55 ± 2.22, P = 0.038) with decreased necrotic core volume and increased dense calcium volume compared to non-statin recipient mild lesions. The key factors for rapid plaque progression were ≥2 HRPs [hazard ratio (HR), 1.89; 95% confidence interval (CI), 1.02-3.49; P = 0.042], current smoking (HR, 1.69; 95% CI 1.09-2.57; P = 0.017), and diabetes (HR, 1.55; 95% CI, 1.07-2.22; P = 0.020).<br /><b>Conclusion</b><br />In mild CAD, statin treatment reduced plaque progression, particularly in lesions with a higher number of HRP features, which was also a strong predictor of rapid plaque progression. Therefore, aggressive statin therapy might be needed even in mild CAD with higher HRPs.<br /><b>Clinical trial registration</b><br />ClinicalTrials.gov NCT02803411.<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 May 2023; epub ahead of print</small></div>

<div><h4>Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve repair.</h4><i>Tanaka T, Sugiura A, Kavsur R, Öztürk C, ... Nickenig G, Weber M</i><br /><b>Aims</b><br />The role of right ventricular function in patients undergoing transcatheter tricuspid valve repair (TTVR) is poorly understood. This study investigated the association of right ventricular ejection fraction (RVEF) assessed by cardiac computed tomography (CCT) with clinical outcomes in patients undergoing TTVR.<br /><b>Methods and results</b><br />We retrospectively assessed three-dimensional (3D) RVEF by using pre-procedural CCT images in patients undergoing TTVR. RV dysfunction was defined as a CT-RVEF of <45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within 1 year after TTVR. Of 157 patients, 58 (36.9%) presented with CT-RVEF <45%. Procedural success and in-hospital mortality were comparable between patients with CT-RVEF <45% and ≥45%. However, CT-RVEF of <45% was associated with a higher risk of the composite outcome (hazard ratio: 2.99; 95% confidence interval: 1.65-5.41; P = 0.001), which had an additional value beyond two-dimensional echocardiographic assessments of RV function to stratify the risk of the composite outcome. In addition, patients with CT-RVEF ≥45% exhibited the association of procedural success (i.e. residual tricuspid regurgitation of ≤2+ at discharge) with a decreased risk of the composite outcome, while this association was attenuated in those with CT-RVEF <45% (P for interaction = 0.035).<br /><b>Conclusion</b><br />CT-RVEF is associated with the risk of the composite outcome after TTVR, and a reduced CT-RVEF might attenuate the prognostic benefit of TR reduction. The assessment of 3D-RVEF by using CCT may refine the patient selection for TTVR.<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 May 2023; epub ahead of print</small></div>

<div><h4>Cardiac magnetic resonance imaging of pericardial diseases: a comprehensive guide.</h4><i>Antonopoulos AS, Vrettos A, Androulakis E, Kamperou C, ... Mohiaddin R, Lazaros G</i><br /><AbstractText>Cardiac magnetic resonance (CMR) imaging has been established as a valuable diagnostic tool in the assessment of pericardial diseases by providing information on cardiac anatomy and function, surrounding extra-cardiac structures, pericardial thickening and effusion, characterization of pericardial effusion, and the presence of active pericardial inflammation from the same scan. In addition, CMR imaging has excellent diagnostic accuracy for the non-invasive detection of constrictive physiology evading the need for invasive catheterization in most instances. Growing evidence in the field suggests that pericardial enhancement on CMR is not only diagnostic of pericarditis but also has prognostic value for pericarditis recurrence, although such evidence is derived from small patient cohorts. CMR findings could also be used to guide treatment de-escalation or up-titration in recurrent pericarditis and selecting patients most likely to benefit from novel treatments such as anakinra and rilonacept. This article is an overview of the CMR applications in pericardial syndromes as a primer for reporting physicians. We sought to provide a summary of the clinical protocols used and an interpretation of the major CMR findings in the setting of pericardial diseases. We also discuss points that are less well clear and delineate the strengths and weak points of CMR in pericardial diseases.</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: 19 May 2023; epub ahead of print</small></div>

<div><h4>Differential biventricular adaption to pulmonary vascular disease in patients with idiopathic/heritable and congenital heart disease: a prospective cardiac magnetic resonance and invasive study.</h4><i>Xu Z, Dou R, Zhou Z, Zhang H, ... Xu L, Gu H</i><br /><b>Aims</b><br />Despite shared pathophysiological mechanisms, patients with idiopathic/heritable pulmonary arterial hypertension (IPAH/HPAH) have a poorer prognosis than those with PAH after congenital heart defect repair. Ventricular adaption remains unclear and could provide a basis for explaining differences in clinical outcomes. The aim of this prospective study was to assess clinical status, haemodynamic profile, and biventricular adaptation to PAH in children with various forms of PAH.<br /><b>Methods and results</b><br />Consecutive patients with IPAH/HPAH or post-operative PAH were prospectively recruited (n = 64). All patients underwent a comprehensive, protocolized assessment including functional assessment, measurement of brain natriuretic peptide (BNP) levels, invasive measurements, and a cardiac magnetic resonance (CMR) assessment. A cohort of age- and sex-matched healthy subjects served as controls. Patients with post-operative PAH had a better functional class (61.5 vs. 26.3% in Class I/II, P = 0.02) and a longer 6-min walk distance (320 ± 193 vs. 239 ± 156 m, P = 0.008) than IPAH/HPAH. While haemodynamic parameters were not significantly different between IPAH/HPAH and post-operative patients, post-operative patients with PAH presented with higher left ventricular volumes and better right ventricular function compared with patients with IPAH/HPAH (P < 0.05). On correlation analyses, left ventricular volumetric parameters were highly correlated with BNP and 6-min walk test distance in this population.<br /><b>Conclusion</b><br />Despite comparable haemodynamic profiles, patients with post-operative PAH had less functional limitation than their IPAH/HPAH counterparts. This is potentially related to the differential biventricular adaptation pattern evident on CMR with better myocardial contractility and higher left ventricular volumes in post-operative patients with PAH, highlighting the importance of ventriculo-ventricular interaction in the setting of PAH.<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: 18 May 2023; epub ahead of print</small></div>

<div><h4>Cardiac rupture in acute myocardial infarction: a cardiac magnetic resonance study.</h4><i>De Lazzari M, Cipriani A, Cecere A, Niero A, ... Iliceto S, Perazzolo Marra M</i><br /><b>Aims</b><br />We assessed the feasibility of cardiac magnetic resonance (CMR) and the role of myocardial strain in the diagnostic work-up of patients with acute myocardial infarction (AMI) and a clinical suspicion of cardiac rupture (CR).<br /><b>Methods and results</b><br />Consecutive patients with AMI complicated by CR who underwent CMR were enrolled. Traditional and strain CMR findings were evaluated; new parameters indicating the relative wall stress between AMI and adjacent segments, named wall stress index (WSI) and WSI ratio, were analysed. A group of patients admitted for AMI without CR served as control. 19 patients (63% male, median age 73 years) met the inclusion criteria. Microvascular obstruction (MVO, P = 0.001) and pericardial enhancement (P < 0.001) were strongly associated with CR. Patients with clinical CR confirmed by CMR exhibited more frequently an intramyocardial haemorrhage than controls (P = 0.003). Patients with CR had lower 2D and 3D global radial strain (GRS) and global circumferential strain (in 2D mode P < 0.001; in 3D mode P = 0.001), as well as 3D global longitudinal strain (P < 0.001), than controls. The 2D circumferential WSI (P = 0.010), as well as the 2D and 3D circumferential (respectively, P < 0.001 and P = 0.042) and radial WSI ratio (respectively, P < 0.001 and P: 0.007), were higher in CR patients than controls.<br /><b>Conclusion</b><br />CMR is a safe and useful imaging tool to achieve the definite diagnosis of CR and an accurate visualization of tissue abnormalities associated with CR. Strain analysis parameters can give insights into the pathophysiology of CR and may help to identify those patients with sub-acute CR.<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: 18 May 2023; epub ahead of print</small></div>