An artificial intelligence-guided quantitative coronary computed tomography angiography model is able to diagnose coronary ischemia by integrating atherosclerosis and vascular morphology measures
Nurmohamed NS, Danad I, Jukema RA, et al.
Development and Validation of a Quantitative Coronary CT Angiography Model for Diagnosis of Vessel-Specific Coronary Ischemia.
JACC Cardiovasc Imaging 2024, S1936-878X(24)00039-1; https://doi.org/10.1016/j.jcmg.2024.01.007
This study is a post hoc analysis of the CREDENCE (Computed Tomographic Evaluation of Atherosclerotic Determinants of Myocardial Ischemia) and PACIFIC-1 (Comparison of Coronary Computed Tomography Angiography, Single Photon Emission Computed Tomography [SPECT], Positron Emission Tomography [PET], and Hybrid Imaging for Diagnosis of Ischemic Heart Disease Determined by Fractional Flow Reserve) studies which included symptomatic patients with suspected stable coronary artery disease who had prospectively undergone coronary computed tomography angiography (CTA), myocardial perfusion imaging (MPI), SPECT, or PET, fractional flow reserve by CT (FFRCT), and invasive coronary angiography in conjunction with invasive FFR measurements. The artificial intelligence-based AI-QCTISCHEMIA model was validate in the CREDENCE validation cohort, with an area under the receiver-operating characteristics curve (AUC) on per-patient level 0.80 (95% CI: 0.75-0.85) for AI-QCTISCHEMIA, compared with 0.69 (95% CI: 0.63-0.74; P < 0.001) for FFRCT, and 0.65 (95% CI: 0.59-0.71; P < 0.001) for MPI. In PACIFIC-1 the AUCs were 0.85 (95% CI: 0.79-0.91) for AI-QCTISCHEMIA, 0.78 (95% CI: 0.72-0.84; P = 0.037) for FFRCT, 0.89 (95% CI: 0.84-0.93; P = 0.262) for PET, and 0.72 (95% CI: 0.67-0.78; P < 0.001) for SPECT. Adjusted for clinical risk factors and coronary CTA-determined obstructive stenosis, a positive AI-QCTISCHEMIA test was associated with an HR of 7.6 (95% CI: 1.2-47.0; P = 0.030) for MACE. This newly developed coronary CTA-based ischemia model, which incorporates coronary atherosclerosis and vascular morphology characteristics, accurately diagnoses coronary ischemia as confirmed by invasive FFR. Additionally, it offers robust prognostic utility for major adverse cardiac events (MACE) beyond the presence of stenosis.
CT
CT, artificial intelligencechronic ischaemic heart disease (including INOCAS)
obstructive CAD, myocardial ischemia
Plaque morphology in acute coronary syndrome differs between younger and older patients: insights from an optical coherence tomography study
Chaudhary G, Gupta B, Roy S, et al.
Differential Culprit Plaque Morphology in Acute Coronary Syndrome: A Comparison Between Very Young Patients (<=35 Years) and Older Counterparts Using Optical Coherence Tomography
Eur Heart J - Imaging Methods and Practice 2024, qyae046; https://doi.org/10.1093/ehjimp/qyae046
This study investigates the underlying mechanisms of acute coronary syndrome (ACS) in young patients (aged ≤35 years) compared to older counterparts (aged >35 years) using optical coherence tomography (OCT). In a prospective, single-center investigation, patients were divided into two age groups and further subdivided based on the underlying ACS mechanism, namely plaque rupture (PR) and plaque erosion (PE). Among the 93 patients analyzed, thin cap fibroatheroma (TCFA) was significantly higher among older patients than very young patients for both PR (80.0% vs. 31.8%, p=0.002) and PE (66.7% vs. 6.3%, p<0.001) groups. Micro-channels were also significantly more prevalent among older than very young patients for both PR (65.0% vs. 18.2%, p=0.004) and PE groups (55.6% vs.12.5%, p=0.013). In contrast, fibrous cap thickness was greater in very young than older patients for both PR (105.71±48.02 µm vs. 58.00±15.76 µm, p<0.001) and PE (126.67±48.22 µm vs. 54.38±24.21 µm, p<0.001) groups. Intimal thickness was greater in older than very young patients for both PR (728.00±313.92 µm vs. 342.27±142.02 µm, p<0.001) and PE (672.78±334.57 µm vs. 295.00±99.60 µm, p<0.001) groups. The study concludes that the frequency of TCFA, micro-channels, macrophages, and intimal thickness was significantly higher in older ACS patients compared to very young patients. Conversely, fibrous cap thickness was significantly greater in very young ACS patients compared to their older counterparts.
Other
Angiography, OCTacute ischaemic heart disease (including MINOCAS)
Acute coronary syndrome
AI-guided plaque and hemodynamic analysis increases the predictability for ACS culprit lesions over conventional coronary CTA analysis.
Koo, B, Yang, S, Jung, J. et al
Artificial Intelligence–Enabled Quantitative Coronary Plaque and Hemodynamic Analysis for Predicting Acute Coronary Syndrome
J Am Coll Cardiol Img 2024; https://doi.org/10.1016/j.jcmg.2024.03.015
This study aimed to investigate the additive value of artificial intelligence-enabled quantitative coronary plaque and hemodynamic analysis (AI-QCPHA) for predicting acute coronary syndrome (ACS). Among patients with ACS who underwent coronary computed tomography angiography (CTA) from 1 month to 3 years before the ACS event, culprit and non-culprit lesions on coronary CTA were adjudicated based on invasive coronary angiography. The primary endpoint was the predictability of the risk models for ACS culprit lesions. The reference model included the CAD-RADS, a standardized classification for stenosis severity, and high-risk plaque, defined as lesions with ≥2 adverse plaque characteristics. The new prediction model was the reference model plus AI-QCPHA features, selected by hierarchical clustering and information gain in the derivation cohort. The model performance was assessed in the validation cohort. In the derivation cohort (n = 243), the best AI-QCPHA features were fractional flow reserve across the lesion, plaque burden, total plaque volume, low-attenuation plaque volume, and averaged percent total myocardial blood flow. In the validation cohort (n=108), the addition of AI-QCPHA features showed higher predictability for ACS than the reference model (AUC: 0.84 vs. 0.78; P< 0.001). The additive value of AI-QCPHA features was consistent across different timepoints from coronary CTA.
CT
CT, artificial intelligenceacute ischaemic heart disease (including MINOCAS)
Acute coronary syndrome
Atherosclerosis imaging-quantitative computed tomography improves diagnostic accuracy, reduces downstream need for non-invasive testing and increases rates of preventive medical therapy
Nurmohamed NS, Cole JH, Budoff MJ, et al.
Impact of atherosclerosis imaging-quantitative computed tomography on diagnostic certainty, downstream testing, coronary revascularization, and medical therapy: the CERTAIN study
Eur Heart J Cardiovasc Imaging 2024,25:857-866; https://doi.org/10.1093/ehjci/jeae029
The aim of this study was to compare the clinical utility, including diagnostic certainty, downstream testing, coronary revascularization, and medical therapy of the routine implementation of atherosclerosis imaging-quantitative computed tomography (AI-QCT) versus conventional visual coronary CT angiography (CCTA) interpretation. AI-QCT is an artificial intelligence-enabled approach that performs whole-heart evaluation of all coronary vessels for atherosclerosis, stenosis, and ischaemia. It has demonstrated robust prognostic utility for near-, intermediate-, and long-term cardiovascular events. Moreover, AI-QCTISCHEMIA has shown accurate performance for diagnosis of coronary ischaemia in a preliminary analysis. In this multi-centre cross-over study 750 consecutive adult patients referred for CCTA were prospectively recruited. Blinded to the AI-QCT analysis, site physicians established patient diagnoses and plans for downstream non-invasive testing, coronary intervention, and medication management based on the conventional site assessment. Next, physicians were asked to repeat their assessments based upon AI-QCT results. Compared with the conventional site CCTA evaluation, AI-QCT analysis improved physician's confidence two- to five-fold at every step of the care pathway and was associated with change in diagnosis or management in the majority of patients (428; 57.1%; P < 0.001), including for measures such as CAD-RADS (295; 39.3%; P < 0.001) and plaque burden (197; 26.3%; P < 0.001). After AI-QCT including ischaemia assessment, the need for downstream non-invasive and invasive testing was reduced by 37.1% (P < 0.001), compared with the conventional site CCTA evaluation. Incremental to the site CCTA evaluation alone, AI-QCT resulted in statin initiation/increase an aspirin initiation in an additional 28.1% (P <0.001) and 23.0% (P < 0.001) of patients, respectively.
CT
CT, artificial intelligencechronic ischaemic heart disease (including INOCAS)
Chronic coronary syndrome
Coronary inflammation predicts adverse cardiovascular events and cardiac mortality independently from the presence or severity of CAD or traditional risk factors, particularly in patients with non-obstructive coronary artery disease
Chan K, Wahome E, Tsiachristas A, et al.
Inflammatory risk and cardiovascular events in patients without obstructive coronary artery disease: the ORFAN multicentre, longitudinal cohort study
Lancet 2024, 403: 2606–18; https://doi.org/10.1016/S0140-6736(24)00596-8
The Oxford Risk Factors And Non-invasive imaging (ORFAN) study hypothesized, that measurement of coronary inflammation through perivascular fat attenuation index (FAI) Score from CCTA can enable cardiovascular risk prediction and guide the management of patients without obstructive CAD. The study aimed to evaluate the risk profile and event rates among patients undergoing CCTA as part of routine clinical care in the UK National Health Service (NHS); to test the hypothesis that coronary arterial inflammation drives cardiac mortality or major adverse cardiac events (MACE) in patients with or without CAD; and to externally validate the performance of the previously trained artificial intelligence (AI)-Risk prognostic algorithm and the related AI-Risk classification system in a UK population. This multicentre, longitudinal cohort study included 40,091 consecutive patients undergoing clinically indicated CCTA who were followed up for MACE for a median of 2.7 years (IQR 1.4–5.3). The prognostic value of FAI Score in the presence and absence of obstructive CAD was evaluated in 3393 consecutive patients with the longest follow-up (7.7 years [6.4–9.1]). An AI-enhanced cardiac risk prediction algorithm, which integrates FAI Score, coronary plaque metrics, and clinical risk factors, was then evaluated in this population. During a 2.7 year median follow-up, patients without obstructive CAD (32,533 [81.1%]) accounted for 2857 (66.3%) of the 4307 total MACE and 1118 (63.7%) of the 1754 total cardiac deaths. The study found that increased FAI Score in all the three coronary arteries had an additive impact on the risk for cardiac mortality (hazard ratio [HR] 29.8 [95% CI 13.9–63.9], p<0.001) or MACE (12.6 [8.5–18.6], p<0.001) comparing three vessels with an FAI Score in the top versus bottom quartile for each artery. FAI Score in any coronary artery predicted cardiac mortality and MACE independently from cardiovascular risk factors and the presence or extent of CAD. The AI-Risk classification was positively associated with cardiac mortality (6.75 [5.17–8.82], p<0.001, for very high risk vs low or medium risk) and MACE (4.68 [3.93–5.57], p<0.001 for very high risk vs low or medium risk).
CT
CT, artificial intelligencechronic ischaemic heart disease (including INOCAS)
Chronic coronary syndrome, non-obstructive CAD
Clinical and prognostic differences between dilated cardiomyopathy and non-dilated left ventricular cardiomyopathy: insight from CMR and genetics
Castrichini M, De Luca A, De Angelis G, et al.
Magnetic Resonance Imaging Characterization and Clinical Outcomes of Dilated and Arrhythmogenic Left Ventricular Cardiomyopathies
J Am Coll Cardiol 2024; 83: 1841-1851; https://doi.org/10.1016/j.jacc.2024.02.041
This study provides a thorough characterization and assess clinical outcomes in a large multicenter cohort of patients with nondilated left ventricular cardiomyopathy (NDLVC) or dilated cardiomyopathy (DCM). A total of 462 patients with DCM (227) or NDLVC (235) with CMR data from 4 different referral centers were retrospectively analyzed. The study endpoint was a composite of sudden cardiac death or major ventricular arrhythmias. In comparison to DCM, NDLVC had a higher prevalence of pathogenic or likely pathogenic variants of arrhythmogenic genes (40% vs 23%; P < 0.001), higher left ventricular (LV) systolic function (LV ejection fraction: 51% ± 12% vs 36% ± 15%; P < 0.001) and higher prevalence of free-wall late gadolinium enhancement (LGE) (27% vs 14%; P < 0.001). Conversely, DCM showed higher prevalence of pathogenic or likely pathogenic variants of non-arrhythmogenic genes (23% vs 12%; P = 0.002) and septal LGE (45% vs 32%; P = 0.004). Over a median follow-up of 81 months (Q1-Q3: 40-132 months), the study outcome occurred in 98 (21%) patients. LGE with septal location (HR: 1.929; 95% CI: 1.033-3.601; P = 0.039) was independently associated with the risk of sudden cardiac death or major ventricular arrhythmias together with LV dilatation, older age, advanced NYHA functional class, frequent ventricular ectopic activity, and non-sustained ventricular tachycardia. In this multicenter cohort of patients with DCM and NDLVC, septal LGE together with LV dilatation, age, advanced disease, and frequent and repetitive ventricular arrhythmias were powerful predictors of major arrhythmic events.
CMR
LGE, fatty infiltration; tissue characterizationcardiomyopathies
dilated cardiomyopathy; arrhythmogenic cardiomyopathy; non-dilated left ventricular cardiomyopathy
Inferolateral mitral valve prolapse and mitral annular disjunction are quite prevalent in patients with idiopathic ventricular fibrillation
Verheul LM, Guglielmo M, Groeneveld SA, et al.
Mitral annular disjunction in idiopathic ventricular fibrillation patients: just a bystander or a potential cause?
Eur Heart J - Cardiovascular Imaging, 2024, 25:764–770; https://doi.org/10.1093/ehjci/jeae054
This study delved into the prevalence and potential arrhythmogenic effects of inferolateral mitral annular disjunction (MAD) in a large cohort of patients with idiopathic ventricular fibrillation (IVF). Conducted as a retrospective multi-center study, it involved 185 IVF patients, characterized by a median age of 39 years, with 40% being female. Researchers utilized cardiac magnetic resonance imaging to detect mitral valve and annular abnormalities, including late gadolinium enhancement, to compare clinical features among patients with and without MAD.
The findings revealed that MAD was present in any of the four designated locations (anterior, anterolateral, inferolateral, inferior) in 61% (112 patients) of the IVF cohort, with inferolateral MAD specifically identified in 13% (24 patients). Additionally, mitral valve prolapse (MVP) was observed in 7% of the IVF patients and was significantly more common in those with inferolateral MAD compared to those without it (42% vs. 2%, P < 0.001).
Moreover, the study highlighted a strong association between inferolateral MAD and pro-arrhythmic indicators. Patients with this condition exhibited a higher frequency of premature ventricular complexes (PVCs) and non-sustained ventricular tachycardia (VT) compared to those without inferolateral MAD (67% vs. 23%, P < 0.001 and 63% vs. 41%, P = 0.046, respectively). However, the rate of appropriate interventions using implantable cardioverter defibrillators during follow-up was similar for IVF patients regardless of the presence of inferolateral MAD (13% vs. 18%, P = 0.579).
Concluding, the study confirmed a notable prevalence of inferolateral MAD and MVP within this IVF population, linked with increased arrhythmic events like PVCs and VT. These findings suggest a need for further exploration into the interplay between MAD, MVP, and arrhythmogenic potential in IVF patients.
CMR
LGE
valvular heart disease (excluded congenital)
mitral valve prolapse, MAD
Three-dimensional echocardiography provides an accurate estimation of biventricular stroke volumes and intracardiac shunt in patients with atrial septal defect
Yanagi Y, Amano M, Tamai Y, et al.
Accuracy of Shunt Volume Measured by Three-Dimensional Echocardiography and Cardiac Magnetic Resonance in Patients With an Atrial Septal Defect and a Dilated Right Ventricle
J Am Soc Echocardiogr 2024, S0894-7317(24)00221-9; https://doi.org/10.1016/j.echo.2024.04.016
This study aimed to evaluate the accuracy of three-dimensional echocardiography (3DE) compared to volumetric cardiac magnetic resonance (CMR) for assessing right ventricular (RV) and left ventricular (LV) stroke volume (SV), as well as the pulmonary to systemic blood flow ratio (Qp/Qs) in patients with atrial septal defect (ASD). Using the two-dimensional phase contrast (2DPC) method as the gold standard, the study involved a retrospective analysis of 83 patients who underwent transcatheter ASD closure and had clinical indications for both CMR and 3DE.
The results showed no significant differences in Qp/Qs values when comparing 2DPC-CMR with both full-volume volumetric 3DE (Vol-3DE) and two-dimensional pulse Doppler quantification (2D-Dop). However, significant discrepancies were noted when comparing 2DPC-CMR with volumetric CMR (Vol-CMR), with 2DPC-CMR providing notably different values. Furthermore, the Qp/Qs values obtained via Vol-3DE correlated best with those from 2DPC-CMR, with a correlation coefficient (r) of 0.93. This strong correlation suggests that 3DE is particularly effective in accurately measuring Qp/Qs in patients with dilated RV due to ASD. Similarly, stroke volumes for both RV and LV measured by Vol-3DE showed the best correlation with the 2DPC-CMR (RV SV r=0.82; LV SV r=0.73), although these measurements tended to be underestimated.
The study concludes that 3DE, specifically Vol-3DE, is more accurate and reliable for evaluating Qp/Qs than Vol-CMR or 2D-Dop in patients with ASD. Moreover, 3DE proves to be a feasible and reproducible method for assessing dilated RV, demonstrating its utility in clinical settings where precise quantification of cardiac function is necessary.
MULTIMODAL
phase contrastcongenital heart disease
Atrial septal defect, shunt
Coronary atherosclerotic plaque activity estimated from coronary 18F-sodium fluoride positron emission tomography predicts incident myocardial infarction
Wang KL, Balmforth C, Meah MN, et al.
Coronary Atherosclerotic Plaque Activity and Risk of Myocardial Infarction
J Am Coll Cardiol 2024, 83(22):2135-2144; https://doi.org/10.1016/j.jacc.2024.03.419
This study investigated whether vessel-level coronary atherosclerotic plaque activity using coronary 18F-sodium fluoride positron emission tomography (PET) is associated with vessel-level myocardial infarction. It consisted in a secondary analysis of an international multicenter study of patients with recent myocardial infarction and multivessel coronary artery disease. Increased 18F-sodium fluoride uptake was found in 679 of 2,094 coronary arteries and 414 of 691 patients. Myocardial infarction occurred in 24 (4%) vessels with increased coronary atherosclerotic plaque activity and in 25 (2%) vessels without increased coronary atherosclerotic plaque activity (HR: 2.08; 95% CI: 1.16-3.72; P = 0.013). This association was not demonstrable in those treated with coronary revascularization (HR: 1.02; 95% CI: 0.47-2.25) but was notable in untreated vessels (HR: 3.86; 95% CI: 1.63-9.10; P-interaction = 0.024). Increased coronary atherosclerotic plaque activity in multiple coronary arteries was associated with heightened patient-level risk of cardiac death or myocardial infarction (HR: 2.43; 95% CI: 1.37-4.30; P = 0.002) as well as first (HR: 2.19; 95% CI: 1.18-4.06; P = 0.013) and total (HR: 2.50; 95% CI: 1.42-4.39; P = 0.002) myocardial infarctions. The Author concluded that coronary atherosclerotic plaque activity prognosticates individual coronary arteries and patients at risk for myocardial infarction.
NUCLEAR
PET CTacute ischaemic heart disease (including MINOCAS)
Atherosclerosis
Apical sparing is not specific to cardiac amyloidosis
Cotella J, Randazzo M, Maurer MS, et al.
Limitations of apical sparing pattern in cardiac amyloidosis: a multicentre echocardiographic study
Eur Heart J Cardiovasc Imaging 2024, 25:754-761; https://doi.org/10.1093/ehjci/jeae021
This study aimed to determine the ability of apical sparing ratio (ASR) and most common echocardiographic parameters to differentiate patients with confirmed cardiac amyloidosis (CA) from those with clinical and/or echocardiographic suspicion of CA but with this diagnosis ruled out. The study included 544 patients with confirmed CA and 200 controls (CTRLs). LV GLS was more impaired (−13.9 ± 4.6% vs. −15.9 ± 2.7%, P < 0.0005), and ASR was higher (2.4 ± 1.2 vs. 1.7 ± 0.9, P < 0.0005) in the CA group vs. CTRL patients. Relative wall thickness and ASR were the most accurate parameters for differentiating CA from CTRL patients [area under the curve (AUC): 0.77 and 0.74, respectively]. However, even with the optimal cut-off of 1.67, ASR was only 72% sensitive and 66% specific for CA, indicating the presence of apical sparing in 32% of CTRL patients. Apical sparing did not prove to be a CA-specific biomarker for accurate identification of CA, when compared with clinically similar CTRLs with no CA.
Echocardiography
Global longitudinal strainamyloidosis
Amyloidosis
Women with non-ischaemic cardiomyopathy show greater concentric remodelling, lower reductions in bi-ventricular function, less replacement fibrosis, but similar prognosis compared to men
Mallabone M, Labib D, Abdelhaleem A, et al.
Sex-based differences in the phenotypic expression and prognosis of idiopathic non-ischaemic cardiomyopathy: a cardiovascular magnetic resonance study
Eur Heart J Cardiovasc Imaging 2024, 25:804-813; https://doi.org/10.1093/ehjci/jeae014
This study aimed to characterize sex-related differences in patients with idiopathic non-ischaemic cardiomyopathy (NICM). A total of 747 NICM patients (531 [71%] males) were enrolled. Z-score values for chamber volumes and function were calculated as standard deviation from mean values of 157 sex-matched healthy volunteers, ensuring reported differences were independent of known sex-dependencies. By Z-score values, females showed significantly higher left ventricular (LV) ejection fraction (EF; median difference 1 SD) and right ventricular (RV) EF (difference 0.6 SD) with greater LV mass (difference 2.1 SD; P < 0.01 for all) vs. males despite similar chamber volumes. Females had a significantly lower prevalence of mid-wall striae (MWS) fibrosis (22% vs. 34%; P < 0.001). Over a median follow-up of 4.7 years, 173 patients (23%) developed the composite outcome (all-cause mortality, heart failure admission, or ventricular arrhythmia), with equal distribution in males and females. LV EF and MWS were significant independent predictors of the outcome (respective HR [95% CI] 0.97 [0.95-0.99] and 1.6 [1.2-2.3]; P = 0.003 and 0.005). There was no association of sex with the outcome. In conclusion, despite similar chamber dilation, females demonstrated greater concentric remodelling, lower reductions in bi-ventricular function, and a lower burden of replacement fibrosis, but their prognosis remained similar to male counterpart.
CMR
CMR, sex-differencescardiomyopathies
idiopathic non ischemic cardiomyopathy, sex differences
Reference values of left atrial strain, volume, and function from 3D echocardiography
Yafasov M, Olsen FJ, Skaarup KG, et al.
Normal values for left atrial strain, volume, and function derived from 3D echocardiography: the Copenhagen City Heart Study.
Eur Heart J Cardiovasc Imaging 2024; 25:602-612; https://doi.org/10.1093/ehjci/jeae018
In this prospective longitudinal cohort study on the general population (5th Copenhagen City Heart Study), 2082 participants underwent 3D echocardiography (3DE) of the left atrium (LA). Healthy participants were included to establish normative values for LA strain, volume, and function by 3DE. The effects of age and sex were also evaluated. After excluding participants with comorbidities, 979 healthy participants (median age 44 years, 39.6% males) remained. The median and limits of normality (2.5th and 97.5th percentiles) for functional and volumetric measures were as follows: LA reservoir strain (LASr) 30.8% (18.4–44.2%), LA conduit strain (LAScd) 19.1% (6.8–32.0%), LA contractile strain 11.7% (4.3–22.2%), total LA emptying fraction (LAEF) 61.4% (47.8–71.0%), passive LAEF 37.7% (17.4–53.9%), active LAEF 37.4% (22.2–52.5%), LA minimum volume index (LAVimin) 10.2 (5.9–18.5) mL/m2, and LA maximum volume index (LAVimax) 26.8 (16.5–40.1) mL/m2. All parameters changed significantly with increasing age. Significant sex-specific differences were observed for all parameters except active LAEF and LAVimax. Sex significantly modified the association between age and LASr, LAScd, LAVimin, and total LAEF such that these parameters deteriorated faster with age in females than males.
ECHO
Echocardiography, 3Dnormal/healthy people
Left atrium
A low Regurgitant volume/left atrial volume ratio predicts a worse prognosis in medically managed patients with severe mitral regurgitation, while transcatheter edge-to-edge repair improves outcomes regardless of baseline RVol/LAV ratio
Coisne A, Scotti A, Granada JF, et al.
Regurgitant volume to LA volume ratio in patients with secondary MR: the COAPT trial
Eur Heart J Cardiovasc Imaging 2024, 25:616-625; https://doi.org/10.1093/ehjci/jead328
In patients from the COAPT trial, the Authors investigated the prognostic impact of pre-procedural mitral regurgitation (MR) severity (Regurgitant volume – RVol) to left atrial volume (LAV) ratio on outcomes among heart failure patients with severe secondary MR randomized to transcatheter edge-to-edge repair plus guideline-directed medical therapy (GDMT) vs. GDMT alone. This index may identify patients with “disproportionate” MR and a higher risk of events. RVol was determined using the proximal isovelocity hemispheric area method on 3 consecutive beats; LAV was assessed by using Simpson’s biplane method. Among 576 patients, the median RVol/LAV was 0.67 (interquartile range 0.48–0.91). In patients randomized to GDMT alone, lower RVol/LAV was independently associated with an increased 2-year risk of heart failure hospitalization, and it was a stronger predictor of adverse outcomes than RVol or LAV alone. Treatment with TEER plus GDMT compared with GDMT alone was associated with lower 2-year rates of heart failure hospitalization both in patients with low and high RVol/LAV. Baseline RVol/LAV ratio was unrelated to 2-year mortality, health status, or functional capacity in either treatment group. Therefore, low RVol/LAV ratio was an independent predictor of 2-year heart failure hospitalization in heart failure patients with severe MR treated with GDMT alone in the COAPT trial. TEER improved outcomes regardless of baseline RVol/LAV ratio.
ECHO
Echocardiographyvalvular heart disease (excluded congenital)
Mitral regurgitation, TEER
A novel echocardiographic index integrating right atrial and right ventricle strain (STREI index) independently predicts cardiovascular outcome
Hinojar R, Fernández-Golfín C, González Gómez A, et al.
STREI: a new index of right heart function in isolated severe tricuspid regurgitation by speckle-tracking echocardiography.
Eur Heart J Cardiovasc Imaging 2024, 25:520-529; https://doi.org/10.1093/ehjci/jead305
In this prospective, single-centre study, 176 patients with severe tricuspid regurgitation (TR) were included. This study aimed to design a novel index by speckle-tracking echocardiography (STREI index) integrating right atrial (RA) and right ventricle (RV) strain information and to evaluate the clinical utility of combining RV and RA strain for prediction of cardiovascular (CV) outcomes. STREI index was developed with the formula: [2 ∗ RV-free wall longitudinal strain (RV-FWLS)] + reservoir RA strain (RASr). The composite endpoint included hospital admission due to heart failure and all-cause mortality. STREI index identified a higher percentage of patients with RV dysfunction compared with conventional parameters. After a median follow-up of 2.2 years, a total of 38% reached the composite endpoint. STREI values were predictors of outcomes independently of TR severity and RV dimensions. The combination of prognostic cut-off values of RASr (<10%) and RV-FWLS (>−20%) (STREI stratification) stratified four different groups of risk independently of TR severity, RV dimensions, and clinical status (adj HR per stratum 1.89 (1.4–2.34), P < 0.001). Pre-defined cut-off values achieved similar prognostic performance in the validation cohort (n = 50). Therefore, STREI index is a novel parameter of RV performance that independently predicts CV events. The combination of RA and RV strain stratifies better patients’ risk, reflecting a broader effect of TR on right heart chambers.
ECHO
Speckle-tracking echocardiographyvalvular heart disease (excluded congenital)
Tricuspid regurgitation
Quantification of Mitral Regurgitation in Mitral Valve Prolapse by Three-Dimensional Vena Contracta Area
Fiore G, Ingallina G, Ancona F, et al.
Quantification of Mitral Regurgitation in Mitral Valve Prolapse by Three-Dimensional Vena Contracta Area: Derived Cutoff Values and Comparison With Two-Dimensional Multiparametric Approach.
J Am Soc Echocardiogr 2024, 37:591-598; https://doi.org/10.1016/j.echo.2024.03.009
The aim of this study was to validate the 3D vena contracta area (VCA) by 3D color-Doppler transesophageal echocardiography (TEE) in patients with mitral valve prolapse (MVP) and to define the cutoff values of severity grading. The secondary aim was to compare 3D VCA to the effective regurgitant orifice area estimation by proximal isovelocity surface area (EROA-PISA) method. A total of 1,138 patients with at least moderate mitral regurgitation (MR) were included. The optimal 3D VCA cutoff value for predicting severe MR was 0.45 cm2 (specificity, 0.87; sensitivity, 0.90) with an AUC of 0.95 using a multiparametric approach as reference. Three-dimensional VCA had a good linear correlation with EROA-PISA (r = 0.62, P < .05) with larger values compared to EROA-PISA (0.63 cm2 vs 0.44 cm2, P < .05). A cutoff of 0.50 cm2 (AUC of 0.84; sensitivity, 0.78; specificity, 0.78) predicts an EROA-PISA of 0.40 cm2. Three-dimensional VCA had a good linear correlation with 3D RV (r = 0.56, P < .01), with an AUC of 0.86 to predict a 3D fraction >50%. The present study suggests 0.45 cm2 as the best cutoff value of 3D VCA to define severe MR in patients with MVP, showing an optimal agreement with the reference standard multiparametric approach and 3D RV.
ECHO
Echocardiography; 3Dvalvular heart disease (excluded congenital)
Mitral regurgitation, Mitral valve prolapse
ECV differentiates cardiac amyloidosis from other causes of LVH, while T2 mapping combined with LGE differentiates AL from ATTR amyloidosis
Kravchenko D, Isaak A, Zimmer S, et al.
Parametric mapping using cardiovascular magnetic resonance for the differentiation of light chain amyloidosis and transthyretin-related amyloidosis.
Eur Heart J Cardiovasc Imaging 2024, jeae154; https://doi.org/10.1093/ehjci/jeae154
The aim of this study was to evaluate different cardiovascular magnetic resonance (CMR) parameters for the differentiation of light chain amyloidosis (AL) and transthyretin-related amyloidosis (ATTR). Overall, 53 patients with cardiac amyloidosis (20 with AL and 33 patients with ATTR) were retrospectively analyzed regarding CMR parameters such as T1 and T2 mapping, extracellular volume (ECV), late gadolinium enhancement (LGE), and myocardial strain, and compared to a control cohort with other causes of left ventricular hypertrophy (LVH; 22 patients). One way-ANOVA and receiver operating characteristic analysis were used for statistical analysis. ECV was the single best parameter to differentiate between cardiac amyloidosis and controls (area under the curve [AUC]: 0.97, 95% confidence intervals [CI]: 0.89-0.99, p<.0001, cutoff: >30%). T2 mapping was the best single parameter to differentiate between AL and ATTR amyloidosis (AL: 63±4 ms, ATTR: 58±2 ms, p<.001, AUC: 0.86, 95% CI: 0.74-0.94, cutoff: >61 ms). Subendocardial LGE was predominantly observed in AL patients (10/20 [50%] vs. 5/33 [15%]; p=.002). Transmural LGE was predominantly observed in ATTR patients (23/33 [70%] vs. 2/20 [10%]; p<.001). The diagnostic performance of T2 mapping to differentiate between AL and ATTR amyloidosis was further increased with the inclusion of LGE patterns (AUC: 0.96, 95% CI: 0.86-0.99]; p=.05). It was concluded that extracellular volume differentiates cardiac amyloidosis from other causes of LVH. T2 mapping combined with late gadolinium differentiates AL from ATTR amyloidosis with high accuracy on a patient level.
CMR
CMR, mappingAmyloidosis
Amyloidosis
Progressive decrease of peak LA strain is associated with the risk of HFpEF, while progressive decrease of pre-atrial indexed LA volumes is associated with the risk of HFrEF
Lim DJ, Varadarajan V, Quinaglia T, et al.
Change in left atrial function and volume predicts incident heart failure with preserved and reduced ejection fraction: Multi-Ethnic Study of Atherosclerosis.
Eur Heart J Cardiovasc Imaging 2024, jeae138; https://doi.org/10.1093/ehjci/jeae138
The aim of this study was to further elucidate the role of change in left atrial (LA) parameters prior to the onset of heart failure. Cardiac magnetic resonance imaging was used to investigate investigate the relationship between longitudinal change in LA function and incident HF in a multi-ethnic population with subclinical cardiovascular disease. In this prospective multi-ethnic cohort study, 2470 participants without known baseline cardiovascular disaese had LA volume and function assessed via multimodality tissue tracking on CMR imaging at baseline (2000-02) and a second study 9.4 ± 0.6 years later. Overall, 73 participants developed incident HF [HF with preserved ejection fraction (HFpEF), n = 39; reduced ejection fraction (HFrEF), n = 34] 7.1 ± 2.1 years after the second study. An annual decrease of 1 SD unit in peak LA strain (ΔLASmax) was most strongly associated with the risk of HFpEF [hazard ratios (HR) = 2.56, 95% confidence interval (CI) (1.34-4.90), P = 0.004], whilst an annual decrease of 1 mL/m2 of pre-atrial indexed LA volumes (ΔLAVipreA) was most strongly associated with the risk of HFrEF [HR = 1.88, 95% CI (1.44-2.45), P < 0.001]. It was concluded that an annual decrease of 1 SD unit in peak LA strain was most strongly associated with the risk of HFpEF, while an annual decrease of 1 mL/m2 of pre-atrial indexed LA volumes was most strongly associated with the risk of HFrEF.
CMR
left atrial functionheart failure
HFpEF, HFrEF
In non-ischaemic left ventricular dysfunction, the presence of LBBB is associated with larger LV cavities and small RV cavities, but has no relationship with scar size, ischaemia or reverse remodelling
Tomoaia R, Harrison P, Bevis L, et al.
CMR characterization of patients with heart failure and left bundle branch block
Eur Heart J Imaging Methods Pract 2024, 2:qyae047; https://doi.org/10.1093/ehjimp/qyae047
The aim of this study was to identify the distinctive cardiovascular magnetic resonance (CMR) features of patients with left bundle branch block (LBBB) and heart failure with reduced ejection fraction (HFrEF) of presumed non-ischaemic aetiology. Patients with HFrEF (LVEF ≤ 40%) on echocardiography were prospectively recruited, after exclusion of coronary artery disease, structural or congenital heart disease. LV recovery was defined as achieving ≥10% absolute improvement to ≥40% in LVEF between baseline evaluation to CMR. A total of 391 patients were recruited including 115 (29.4%) with LBBB. Compared with HF patients without LBBB, those with LBBB exhibited larger left ventricles and smaller right ventricles, but no differences were observed with respect to LVEF (36±12 vs. 38±12%, P = 0.105), scar or ischaemia. The overall rate of LV recovery from baseline echocardiogram to CMR (70 [42-128] days) was not significantly different between LBBB and non-LBBB patients (28% vs. 32%, P = 0.47). Reduced LVEF remained an independent predictor of LV non-recovery only in patients with LBBB. In conclusion, patients presenting with HFrEF and LBBB had larger LV cavities and smaller RV cavities than those without LBBB but no difference in prevalence of scar or ischaemia. The rates of LV recovery were similar between both groups, which supports current guidelines to defer device therapy until 3–6 months of guideline-directed medical therapy, rather than early CMR and device implantation.
CMR
heart failure
Cardiomyopathy, LBBB
The GLIDE (Gap, Location, Image quality, density, en-face TR morphology) score predicts procedural success of tricuspid valve transcatheter edge-to-edge repair
Gerçek M, Narang A, Körber MI, et al.
GLIDE Score: Scoring System for Prediction of Procedural Success in Tricuspid Valve Transcatheter Edge-to-Edge Repair
JACC Cardiovasc Imaging 2024, 17:729-742; https://doi.org/10.1016/j.jcmg.2024.04.008
This study developed an anatomical score to predict tricuspid valve transcatheter edge-to-edge repair (T-TEER) outcomes, including 168 patients in a derivation cohort and 126 in a validation cohort. Core laboratory assessment of procedural transesophageal echocardiograms was used to determine septolateral and anteroposterior coaptation gap, leaflet morphology, septal leaflet length and retraction, chordal structure density, tethering height, en face TR jet morphology and TR jet location, image quality, and the presence of intracardiac leads. A scoring system was derived using univariable and multivariable logistic regression. Endpoints assessed were immediate postprocedural TR reduction ≥2 grades and TR grade moderate or less. The median age was 82, with 48% women, and patients had severe (55%), massive (36%), and torrential (8%) TR. Five variables (septolateral coaptation gap, chordal structure density, en face TR jet morphology, TR jet location, and image quality) were identified as best predicting procedural outcome and were incorporated in the GLIDE (Gap, Location, Image quality, density, en-face TR morphology) score (range 0-5). The GLIDE score effectively predicted procedural outcomes, with >90% TR reduction and moderate or less TR in patients with scores of 0-1, but only 5.6% and 16.7% in those with scores ≥4. External validation showed an AUC of 0.77. TR reduction was linked to functional improvement at 3 months. The GLIDE score is a simple, effective tool for predicting successful T-TEER.
ECHO
Echo; structuralvalvular heart disease (excluded congenital)
Tricuspid regurgitation
Asymptomatic valvular heart disease is present in 28% of otherwise healthy individuals aged >60 Years, but moderate or severe disease in only 2.4%
Tsampasian V, Militaru C, Parasuraman SK, et al.
Prevalence of asymptomatic valvular heart disease in the elderly population: a community-based echocardiographic study
Eur Heart J Cardiovasc Imaging 2024, jeae127; https://doi.org/10.1093/ehjci/jeae127
This study aimed to determine the prevalence of asymptomatic valvular heart disease (VHD) in individuals aged 60 and older and to evaluate the feasibility of echocardiographic screening. Conducted in the UK between 2007 and 2016, 10,000 asymptomatic patients with no prior indication for echocardiography were invited, and 5429 volunteered, with 4237 being eligible. VHD was found in 28.2% of patients (25.8% mild, 2.2% moderate, 0.2% severe), with tricuspid (13.8%), mitral (12.8%), and aortic (8.3%) regurgitation being the most common types. Clinically significant (moderate or severe) VHD prevalence was 2.4%, predominantly mitral and aortic regurgitation. Age was the only significant predictor of VHD, with an odds ratio of 1.07 per year increase. The number needed to scan to diagnose one case of significant (moderate or severe) VHD was 42 for those aged 60 and older, and 15 for those aged 75 and older. The study concluded that a significant proportion of otherwise healthy individuals over 60 have asymptomatic VHD, with age being a strong predictor.
ECHO
Echo, aging, valve diseasevalvular heart disease (excluded congenital)
Valve disease
Prevalence of atherosclerosis in ancient mummies
Thompson RC, Sutherland ML, Allam AH, et al.
Atherosclerosis in ancient mummified humans: the global HORUS study
Eur Heart J 2024, ehae283; https://doi.org/10.1093/eurheartj/ehae283
Atherosclerosis is thought of as a disease of modern times. In this study, the Authors explore the presence of atherosclerotic calcifications by CT in multiple vascular districts in 237 adult mummies from a variety of cultures and housed at numerous museums and collections. Calcifications in the wall of an identifiable artery were considered definite atherosclerosis, and calcifications along the expected course of an artery were considered probable atherosclerosis. The extent of atherosclerosis was assessed by counting the number of different vascular beds involved (aorta, ileo-femoral, popliteal-tibial, carotid, and coronaries). Age at time of death and sex were estimated using standard criteria. Estimated age was a predictor of involvement of multiple vascular beds (P < .002). The results suggest that atherosclerosis is ubiquitous in human populations distributed temporally and geographically since ancient times, being seen in 37.6% of the sample and in similar frequencies in men and women. These findings support the concept that modern cardiovascular risk factors superimpose on an underlying, inherent risk driving the extent and impact, rather than the basic prevalence risk, of atherosclerosis.
CT
CTvascular diseases
Atherosclerosis
Coronary microcalcifications detected by 18F-NaF PET are a strong predictor of future myocardial infarction regardless of sex
Kwiecinski J, Wang KL, Tzolos E, et al.
Sex differences in coronary atherosclerotic plaque activity using (18)F-sodium fluoride positron emission tomography.
Eur J Nucl Med Mol Imaging 2024; https://doi.org/10.1007/s00259-024-06810-x
Atherosclerotic plaque activity was measured using coronary 18F-sodium fluoride (18F-NaF) positron emission tomography (PET), in a large observational cohort of 999 patients (151 (15%) women) with coronary atherosclerosis and correlated with prognosis over a median follow-up of 4.5 yrs. Compared to men, women had lower coronary calcium scores (116 [interquartile range, 27-434] versus 205 [51-571] Agatston units; p = 0.002) and coronary microcalcification activity (CMA) values (0.0 [0.0-1.12] versus 0.53 [0.0-2.54], p = 0.01). Following matching for plaque burden by coronary calcium scores and clinical comorbidities, there was no sex-related difference in CMA values (0.0 [0.0-1.12] versus 0.0 [0.0-1.23], p = 0.21) and similar proportions of women and men had no 18F-NaF uptake (53.0% (n = 80) and 48.3% (n = 73); p = 0.42), or CMA values > 1.56 (21.8% (n = 33) and 21.8% (n = 33); p = 1.00). Over a median follow-up of 4.5 [4.0-6.0] years, myocardial infarction occurred in 6.6% of women (n = 10) and 7.8% of men (n = 66). Coronary microcalcification activity greater than 0 was associated with a similarly increased risk of myocardial infarction in both women (HR: 3.83; 95% CI:1.10-18.49; p = 0.04) and men (HR: 5.29; 95% CI:2.28-12.28; p < 0.001). In conclusion, although men present with more coronary atherosclerotic plaque than women, increased plaque activity is a strong predictor of future myocardial infarction regardless of sex.
NUCLEAR
PET, 18F-sodium fluoridechronic ischaemic heart disease (including INOCAS)
Vulnerable plaques
A novel artificial intelligence-guided quantitative computed tomography ischaemia algorithm (AI-QCTischaemia) predicts major events, mainly in patients with no or non-obstructive coronary artery disease
Bär S, Nabeta T, Maaniitty T, wt al.
Prognostic value of a novel artificial intelligence-based coronary computed tomography angiography-derived ischaemia algorithm for patients with suspected coronary artery disease
Eur Heart J Cardiovasc Imaging 2024, 25:657-667; https://doi.org/10.1093/ehjci/jead339
A novel artificial intelligence-guided quantitative computed tomography ischaemia algorithm (AI-QCTischaemia, designed to identify myocardial ischaemia directly from CTA images) was tested as prognostic determinant in a large population of symptomatic patients with suspected CAD. The aims were to investigate (i) the prognostic value of AI-QCTischaemia amongst symptomatic patients with suspected CAD entering diagnostic imaging with coronary CTA and (ii) the prognostic value of AI-QCTischaemia separately amongst patients with no/non-obstructive CAD (≤50% visual diameter stenosis) and obstructive CAD (>50% visual diameter stenosis). A total of 1880/2271 (83%) patients had conclusive AI-QCTischaemia result. Patients with an abnormal AI-QCTischaemia result (n = 509/1880) vs. patients with a normal AI-QCTischaemia result (n = 1371/1880) had significantly higher adjusted rates of major events (death, MI or unstable angina) after correction for risk factors and symptoms. When the presence and severity of CAD at CTCA was considered this association remained significant in patients with no/non-obstructive disease but not in patients with obstructive CAD.
CT
CT Perfusion, Artificial Intelligencechronic ischaemic heart disease (including INOCAS)
Myocardial Ischemia and Prognosis
Mitral annular disjunction is common in consecutive patients undergoing CMR, but it is weakly associated with ventricular arrhythmias only for greater extents
Figliozzi S, Stankowski K, Tondi L, et al.
Mitral Annulus Disjunction in consecutive patients undergoing Cardiac Magnetic Resonance: where is the boundary between normality and disease?
JCMR 2024; https://doi.org/10.1016/j.jocmr.2024.101056
The presence of mitral annulus disjunction (MAD) has been considered a high-risk feature for ventricular arrhythmias, but its prevalence in the general population is unknown. This single-center retrospective study included 441 patients referred to CMR for any reason. MAD was defined as a ≥1 mm displacement between the left atrial wall-mitral valve leaflet junction and the left ventricular wall during end-systole. The MAD extent was defined as the maximum longitudinal displacement in any long-axis view , excluding the interventricular septum. Mitral valve prolapse (MVP) was defined as a systolic displacement ≥2.0 mm of one or both mitral valve leaflets above the annulus in 3-chamber long-axis view. The study endpoint included (aborted) sudden cardiac death, unexplained syncope, and sustained ventricular tachycardia at 12-month follow-up. Overall, MVP was present in 29 (7%) of patients, while MAD ≥1 mm, 4 mm, and 6 mm in 214 (49%), 63 (14%), and 15 (3%), respectively. MVP was the only morpho-functional abnormality associated with MAD at multivariable analysis (p<0.001). A high burden of ventricular ectopic beats at baseline Holter-ECG was associated with MAD ≥4 mm and MAD extent (p<0.05). The presence of MAD ≥1 mm (0.9% vs. 1.8%; p=0.46), MAD ≥4 mm (1.6% vs. 1.3%; p=0.87), or MVP (3.5% vs. 1.2%; p=0.32) were not associated with the study endpoint, whereas patients with MAD ≥6 mm showed a trend towards a higher likelihood of the study endpoint (6.7% vs. 1.2%; p=0.07). In conclusion, a MAD of limited entity is common in consecutive patients undergoing CMR, while extended MAD is rarer and showed a weak association with ventricular arrhythmias.
CMR
mitral valvevalvular heart disease (excluded congenital)
MVP, MAD
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