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  • Septal contraction predicts acute haemodynamic improvement and paced QRS width reduction in cardiac resynchronization therapy
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2020-01-10
    Ross S, Nestaas E, Kongsgaard E, et al.

    Aims Three distinct septal contraction patterns typical for left bundle branch block may be assessed using echocardiography in heart failure patients scheduled for cardiac resynchronization therapy (CRT). The aim of this study was to explore the association between these septal contraction patterns and the acute haemodynamic and electrical response to biventricular pacing (BIVP) in patients undergoing CRT implantation. Methods and results Thirty-eight CRT candidates underwent speckle tracking echocardiography prior to device implantation. The patients were divided into two groups based on whether their septal contraction pattern was indicative of dyssynchrony (premature septal contraction followed by various amount of stretch) or not (normally timed septal contraction with minimal stretch). CRT implantation was performed under invasive left ventricular (LV) pressure monitoring and we defined acute CRT response as ≥10% increase in LV dP/dtmax. End-diastolic pressure (EDP) and QRS width served as a diastolic and electrical parameter, respectively. LV dP/dtmax improved under BIVP (737 ± 177 mmHg/s vs. 838 ± 199 mmHg/s, P < 0.001) and 26 patients (68%) were defined as acute CRT responders. Patients with premature septal contraction (n = 27) experienced acute improvement in systolic (ΔdP/dtmax: 18.3 ± 8.9%, P < 0.001), diastolic (ΔEDP: −30.6 ± 29.9%, P < 0.001) and electrical (ΔQRS width: −23.3 ± 13.2%, P < 0.001) parameters. No improvement under BIVP was observed in patients (n = 11) with normally timed septal contraction (ΔdP/dtmax: 4.0 ± 7.8%, P = 0.12; ΔEDP: −8.8 ± 38.4%, P = 0.47 and ΔQRS width: −0.9 ± 11.4%, P = 0.79). Conclusion Septal contraction patterns are an excellent predictor of acute CRT response. Only patients with premature septal contraction experienced acute systolic, diastolic, and electrical improvement under BIVP.

  • Giant venous aneurysm arising from the brachiocephalic vein
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2020-01-13
    Shen J, Fang Z, Guo Y.

    A 41-year-old woman was referred to our clinic for an incidental X-ray finding of abnormal contour and widening of right border of mediastinum (Panel A, arrow). Even though the patient was reported to have right-sided clavicle fracture in a car accident 16 years ago, no complications were left. Physical examinations also revealed no abnormalities. Transthoracic echocardiography identified an abnormal communication between a circumscribed echolucent mass with no intracavity thrombus and brachiocephalic vein (Panel B, arrow; Supplementary data online, Movie S1). A further computerized tomography angiography (CTA) demonstrated a giant aneurysm arising from left-sided brachiocephalic vein, compressing the adjacent superior vena cava (Panels C and D, 5.7 × 4.0 cm in short-axis, arrow and asterisk; Supplementary data online, Movies S2 and S3). The patient received surgical intervention without cardiopulmonary bypass. After partial median sternotomy, the aneurysm-like mass was exposed at the surface of left-sided brachiocephalic vein and superior vena cava (Panel E). We performed complete aneurysm resection and the neck of the aneurysm was subsequently continuously sutured with 5-0 prolene. Post-operative CTA scan revealed the disappearance of the mediastinal aneurysm (Panel F) and the pathologic examination of the aneurysmal wall confirmed no existence of chronic vasculitis (Panel G). The patient recovered without complications and was discharged home on the fourth day later.

  • Echocardiographic features in antiphospholipid-negative Sneddon’s syndrome and potential association with severity of neurological symptoms or recurrence of strokes: a longitudinal cohort study
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2020-01-03
    Assan F, de Zuttere D, Bottin L, et al.

    AimsSneddon’s syndrome (SS) may be classified as antiphospholipid positive (aPL+) or negative (aPL− SS). An association between Libman–Sacks (LS) endocarditis and strokes has been described in aPL+ patients. To describe cardiac involvement in aPL− SS and assess the potential association between LS endocarditis and severity or recurrence of neurological symptoms. Methods and resultsThis longitudinal cohort study included aPL− SS patients followed in our departments between 1991 and June 2018. All patients underwent transthoracic 2D and Doppler echocardiography at diagnosis. Follow-up echocardiography was performed annually and the potential relationship between LS endocarditis development and neurovascular relapse as well as long-term cardiac worsening was prospectively assessed. We included 61 patients [52 women; median age 45 (range 24–60)]. For valvular involvement, 36 (59%) patients showed leaflet thickening; 18 (29.5%) had LS endocarditis at baseline. During a median follow-up of 72 months, LS endocarditis developed in eight (17.4%) patients, and 13 (28.3%) showed significant worsening of their cardiac status, including two who needed valvular replacement. After adjusting for baseline antithrombotic treatment regimen, neither the presence of LS endocarditis at baseline nor development during follow-up was associated with neurological relapse [hazard ratio (HR): 1.06, 95% confidence interval (CI): 0.33–4.74, P = 0.92] and [HR: 0.38, 95% CI: 0.02–1.89, P = 0.31], respectively. ConclusionA long-term follow-up is needed to detect cardiac complications in aPL− SS. No change in neurological relapse was observed in patients presenting LS endocarditis occurrence during follow-up without any modification in antithrombotic treatment. Further research is necessary to assess the usefulness of treatment escalation in these patients.

  • Right atrial congenital aneurysm
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-26
    Xiao Y, Cai Y, Dian K, et al.

    A 30-year-old gentleman with no significant medical history presented with gradually worsening palpitations and fatigue over 3 weeks. He had several self-resolving episodes of mild palpitations and fatigue since 14 years of age, usually triggered by viral upper respiratory tract infections. Electrocardiogram (ECG) showed atrial flutter and incomplete right bundle branch block (Panel A). Echocardiography demonstrated a disproportionately enlarged right atrium (RA) (194 mm × 92 mm) compared to the rest of the cardiac chambers (Panel B, Supplementary dataSupplementary data online, Movie SI), with moderate tricuspid regurgitation (TR) (vena contracta width 5 mm, velocity 2.5 m/s, Panel C, Supplementary dataSupplementary data online, Movie SII), likely a result of annular dilatation (51 mm). Redundancy of the tricuspid valve (TV) was noted, but without prolapse or displacement (Panel D). Cardiac magnetic resonance imaging (MRI) showed an enlarged RA, without late gadolinium enhancement (Panels E and F).

  • Primum atrial septal laceration following coronary sinus lead extraction
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-26
    Librera M, Carlomagno G, Calvanese C, et al.

    A 61-year-old man was admitted to our hospital (Mediterranea Cardiocentro, Naples, Italy) for deep pocket infection of a cardiac resynchronization device implanted 11 years earlier; an indication to complete removal of the device was posed.

  • Progressive myocardial lipomatous metaplasia following acute myocarditis
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-26
    Moura-Ferreira S, Van Cleemput J, Verbeken E, et al.

    In 2012, a 17-year-old boy was referred to cardiac magnetic resonance (CMR) for suspected acute viral myocarditis.

  • Predictive value of non-invasive right ventricle to pulmonary circulation coupling in systemic lupus erythematosus patients with pulmonary arterial hypertension
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-23
    Guo X, Lai J, Wang H, et al.

    AimsPulmonary arterial hypertension (PAH) is a serious and devastating complication of systemic lupus erythematosus (SLE), especially when the right ventricle (RV) fails. Whether the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) measured by echocardiography as a simple surrogate of RV to pulmonary circulation (PC) coupling predicts the outcome of SLE-associated PAH has not been investigated. Methods and resultsBetween February 2010 and August 2015, 112 consecutive patients with a diagnosis of SLE-associated PAH confirmed by right heart catheterization were enrolled prospectively. The endpoint was a composite of all-cause mortality and clinical worsening. Baseline clinical characteristics and echocardiographic assessment were analysed. Among all the patients, 47 (42%) patients experienced the endpoint (mean follow-up period 18.1 ± 12.0 months), including 20 patients who died during a median follow-up period of 48.5 months. Multivariable Cox regression analysis showed that TAPSE/PASP ratio [hazard ratio (HR) 0.004, P=0.017] and 6-min walk distance (6MWD) (HR 0.997, P=0.036) were the independent predictors for the endpoint. A three-group prediction risk was created based on combined assessment of the TAPSE/PASP ratio and 6MWD relative to their cut-off values. The patients with the worse RV-PC coupling (TAPSE/PASP <0.184 mm/mmHg) and the lower 6MWD (<395 m) had the highest risk (HR 4.62, confidence interval 2.27–9.41, P<0.001) of experiencing the endpoint. ConclusionThe TAPSE/PASP ratio, combined with 6MWD, provides clinical and prognostic insights into patients with SLE-associated PAH. A low TAPSE/PASP and low 6MWD identifies the subgroup of patients with high risk of poor prognosis.

  • The independent and incremental value of ultrasound carotid plaque length to predict the presence and severity of coronary artery disease: analysis from the carotid plaque length prospective registry
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-17
    Tang W, Shen X, Li H, et al.

    Aims Data regarding the relationship between carotid plaque length (CPL) and coronary artery disease (CAD) are lacking. This study aimed to assess the predictive value of CPL for the severity of CAD. Methods and resultsWe prospectively enrolled 2149 consecutive patients who underwent both first coronary angiography and carotid ultrasonography with measurements of intima-media thickness (IMT), plaque score (PS), and CPL. In total, 1408 (65.5%) patients had CAD (defined as stenosis ≥50%), and 741 (34.5%) patients had no CAD. Patients with CAD had longer maximal CPL than those without CAD (P<0.001). The severity of CAD, measured by the Gensini score (GS), was closely correlated with max-CPL (rs = 0.560), followed by PS (rs = 0.486) and mean-IMT (rs = 0.292). Multivariate analysis revealed that max-CPL remained independently associated with CAD and high-GS after adjustment for traditional risk factors (TRF). Max-CPL, compared with PS or mean-IMT, had significantly higher discrimination value for predicting high-GS [area under the curve (AUC) 0.819 vs. 0.769 vs. 0.634, P<0.001]. At a cut-off value for the max-CPL of 6.3 mm, the sensitivity and negative predictive value for high-GS were 84.6% and 89.1%, respectively. Furthermore, the addition of max-CPL significantly improved the discrimination (AUC 0.832 vs. 0.720, P<0.001) and reclassification (net reclassification improvement = 0.431, P<0.001) over TRF for high-GS. Conclusion Ultrasound max-CPL provides independent and incremental predictive value for the clinical severity of CAD over TRF and seems a simple useful marker in CAD risk stratification.

  • Eosinophilic granulomatosis with polyangiitis associated myocarditis: role of myocardial tissue characterization
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-17
    Voon V, Chikanza I, Khanji M.

    A 73-year-old woman was admitted with a 4-day history of breathlessness, wheeze, left upper quadrant, and epigastric pain. She was asthmatic and underwent lobectomy the previous year for lung carcinoid (pT1apN0M0). Blood biochemistry showed eosinophilia (14 × 10×9/L, normal <0.5 × 10×9/L) and rising serial troponin levels (peak 1750 ng/L, normal <14 ng/L) with normal lipase, TFTs, and ANCA. Electrocardiogram showed sinus rhythm with left bundle branch block (Panel A). Positron emission tomography showed bilateral hilar adenopathy but no metabolic activity (Panel B, arrowheads). Cardiovascular magnetic resonance (CMR) imaging demonstrated mildly dilated left ventricle (LV), mild global systolic impairment (ejection fraction 42%) with patchy, diffuse, circumferential subendocardial LV fibrosis on late gadolinium enhancement (LGE, Panel C, arrows), supported by elevated T1 values (peak 1205 ms, normal 1020 ± 60 ms, Panel D) with marginally elevated T2 values suggesting mild oedema (peak 56 ms, normal < 55 ms) (Panel E). Bone marrow trephine demonstrated hyperplastic eosinophilic granulopoiesis. Findings were consistent with eosinophilic granulomatosis with polyangiitis (EGPA, previously Churg–Strauss syndrome)-related myocarditis. High-dose intravenous methylprednisolone induced clinical improvement and a rapid reduction in eosinophilia (4 × 10×9/L).

  • Characteristics of non-culprit plaques in acute coronary syndrome patients with layered culprit plaque
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-17
    Russo M, Kim H, Kurihara O, et al.

    Aims Layered plaques represent signs of previous plaque destabilization. A recent study showed that acute coronary syndrome (ACS) patients with layered culprit plaque have more vulnerability at the culprit lesion and systemic inflammation. We aimed to compare the characteristics of non-culprit plaques between patients with or without layered plaque at the culprit lesion. We also evaluated the characteristics of layered non-culprit plaques, irrespective of culprit plaque phenotype. Methods and resultsWe studied ACS patients who had undergone pre-intervention optical coherence tomography (OCT) imaging. The number of non-culprit lesions was evaluated on coronary angiogram and morphological characteristics of plaques were studied by OCT. In 349 patients, 99 (28.4%) had layered culprit plaque. The number of non-culprit plaques in patients with or without layered culprit plaque was similar (3.2 ± 0.8 and 2.8 ± 0.8, P = 0.23). Among 465 non-culprit plaques, 145 from patients with layered culprit plaque showed a higher prevalence of macrophage infiltration (71.0% vs. 60.9%, P = 0.050). When analysed irrespective of culprit plaque phenotype, layered non-culprit plaques showed higher prevalence of lipid (93.3% vs. 86.0%, P = 0.028), thin cap fibroatheroma (29.7% vs. 13.7%, P < 0.001), and macrophage infiltration (82.4% vs. 54.0%, P < 0.001) than non-layered plaques. Plaques with layered phenotype at both culprit and non-culprit lesions had the highest vulnerability. Conclusion In ACS patients, those with layered phenotype at the culprit lesion demonstrated greater macrophage infiltration at the non-culprit sites. Layered plaque at the non-culprit lesions was associated with more features of plaque vulnerability, particularly when the culprit lesion also had a layered pattern.

  • Left atrial strain: a multi-modality, multi-vendor comparison study
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-17
    Pathan F, Zainal Abidin H, Vo Q, et al.

    AimsLeft atrial (LA) strain is a prognostic biomarker with utility across a spectrum of acute and chronic cardiovascular pathologies. There are limited data on intervendor differences and no data on intermodality differences for LA strain. We sought to compare the intervendor and intermodality differences between transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) derived LA strain. We hypothesized that various components of atrial strain would show good intervendor and intermodality correlation but that there would be systematic differences between vendors and modalities. Methods and resultsWe evaluated 54 subjects (43 patients with a clinical indication for CMR and 11 healthy volunteers) in a study comparing TTE- and CMR-derived LA reservoir strain (ƐR), conduit strain (ƐCD), and contractile strain (ƐCT). The LA strain components were evaluated using four dedicated types of post-processing software. We evaluated the correlation and systematic bias between modalities and within each modality. Intervendor and intermodality correlation was: ƐR [intraclass correlation coefficient (ICC 0.64–0.90)], ƐCD (ICC 0.62–0.89), and ƐCT (ICC 0.58–0.77). There was evidence of systematic bias between vendors and modalities with mean differences ranging from (3.1–12.2%) for ƐR, ƐCD (1.6–8.6%), and ƐCT (0.3–3.6%). Reproducibility analysis revealed intraobserver coefficient of variance (COV) of 6.5–14.6% and interobserver COV of 9.9–18.7%. ConclusionVendor derived ƐR, ƐCD, and ƐCT demonstrates modest to excellent intervendor and intermodality correlation depending on strain component examined. There are systematic differences in measurements depending on modality and vendor. These differences may be addressed by future studies, which, examine calibration of LA geometry/higher frame rate imaging, semi-quantitative approaches, and improvements in reproducibility.

  • R2 prime (R2′) magnetic resonance imaging for post-myocardial infarction intramyocardial haemorrhage quantification
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-17
    Rossello X, Lopez-Ayala P, Fernández-Jiménez R, et al.

    AimsTo assess whether R2* is more accurate than T2* for the detection of intramyocardial haemorrhage (IMH) and to evaluate whether T2′ (or R2′) is less affected by oedema than T2* (R2*), and thus more suitable for the accurate identification of post-myocardial infarction (MI) IMH. Methods and resultsReperfused anterior MI was performed in 20 pigs, which were sacrificed at 120 min, 24 h, 4 days, and 7 days. At each time point, cardiac magnetic resonance (CMR) T2- and T2*-mapping scans were recorded, and myocardial tissue samples were collected to quantify IMH and myocardial water content. After normalization by the number of red blood cells in remote tissue, histological IMH increased 5.2-fold, 10.7-fold, and 4.1-fold at Days 1, 4, and 7, respectively. The presence of IMH was correlated more strongly with R2* (r = 0.69; P = 0.013) than with T2* (r = −0.50; P = 0.085). The correlation with IMH was even stronger for R2′ (r = 0.72; P = 0.008). For myocardial oedema, the correlation was stronger for R2* (r = −0.63; P = 0.029) than for R2′ (r = −0.50; P = 0.100). Multivariate linear regressions confirmed that R2* values were significantly explained by both IMH and oedema, whereas R2′ values were mostly explained by histological IMH (P = 0.024) and were little influenced by myocardial oedema (P = 0.262). ConclusionUsing CMR mapping with histological validation in a pig model of reperfused MI, R2′more accurately detected IMH and was less influenced by oedema than R2* (and T2*). Further studies are needed to elucidate whether R2′ is also better suited for the characterization of post-MI IMH in the clinical setting.

  • The left atrium: a mirror of ventricular systolic and diastolic function
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-16
    Smiseth O, Inoue K.

    This editorial refers to ‘Potential usefulness and clinical relevance of a novel left atrial filling index to estimate left ventricular filling pressures in patients with preserved left ventricular ejection fraction’, by K. Braunauer et al., doi: 10.1093/ehjci/jez272.

  • EACVI communication paper: first international young dedicated multimodal cardiovascular imaging simulation education event organized by the ESC
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-13
    Pezel T, Coisne A, Mahmoud-Elsayed H, et al.

    simulation-based trainingcardiovascular imagingechocardiographycardiac magnetic resonance

  • Unusual presentation of Ehlers–Danlos with arteriovenous malformations
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-11
    Elnagar M, Kurmann R, Pislaru S, et al.

    A 33-year-old woman with a history of radical thyroidectomy for papillary thyroid carcinoma presented with a year long history of dizziness and fatigue, which progressed to the point of limited activity. Additionally, she reported significant orthostatic presyncopal symptoms. At an outside institution, she was found to have thoracic arteriovenous malformations (AVM) by magnetic resonance imaging. Her orthostatic symptoms were labelled postural orthostatic tachycardia syndrome. Transthoracic echo showed multiple areas of colour Doppler flow located on the lesser curvature of the aortic arch, consistent with a small intrapulmonary shunt (Panel A (arrows), Supplementary dataSupplementary data online, Video S1). A later computed tomography (CT) showed prominent bronchial collateral vessels in the mediastinum and right hilum with mild focal enlargement of lower lobe branches of the right pulmonary artery, as well as an anomalous right subclavian artery from the posterior aortic arch with a retro-oesophageal course (Panel B (arrow), Supplementary dataSupplementary data online, Video S2). The patient was offered treatment and opted for embolization which was performed on a tortuous bronchial arterial branch. Unfortunately, a follow-up CT a year later showed no significant interval change in the systemic to right pulmonary artery malformation/fistula, with systemic supply arising predominantly from the right internal mammary and an ectopic bronchial artery branch arising from the upper right subclavian artery. The AVM prompted screening for connective tissue disease, and the patient was found to meet clinical criteria for Ehlers–Danlos syndrome, hypermobility type.

  • A rare combination of quadricuspid pulmonary valve
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-09
    Wei X, Zheng Y, Zheng H, et al.

    An 8-month-old man admitted to our hospital for a systolic murmur without any discomfort 4 months ago. Auscultation revealed a Grade 3/6 systolic murmur at the left sternal border (second intercostal space). Transthoracic echocardiography (TTE) showed his quadricuspid pulmonary valve (QPV) was equal to a characteristic ‘+’ configuration (Panels A and B and Supplementary data onlineSupplementary data online, Video S1), indicating a Type A QPV. Severe pulmonary valve stenosis (PS) was indicated by high transvalvular flow velocity (4.4 m/s, Panel C). In the proximal dilated main pulmonary artery from the lateral aspect, an unusual flow was observed (Panels D and E and Supplementary data onlineSupplementary data online, Video S2) with a velocity of 2.4 m/s at diastole (Panel F) indicating a coronary-pulmonary micro-fistulae (CPMF); while bidirectional shunt flow through fossa ovalis indicated patent foramen ovale (PFO) for the patient (Panels G and H). After treatment of percutaneous balloon pulmonary valvuloplasty, the degree of PS went to mild with a transvalvular flow velocity of 2.9 m/s (Panel I), PFO shunt direction turned from the left to right. Due to the small shunt volume of CPMF, only a long-term follow-up was performed.

  • EACVI survey on standardization of cardiac chambers quantification by transthoracic echocardiography
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-09
    Ajmone Marsan N, Michalski B, Cameli M, et al.

    AimsTo evaluate standard reporting of cardiac chambers size and function by transthoracic echocardiography (TTE), the EACVI Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of three-dimensional echocardiography (3DE) and speckle tracking-derived myocardial deformation imaging (STE) was explored. Methods and resultsA total of 96 European Echocardiography Laboratories from 22 different countries responded to the survey, which consisted of 20 questions. For most of the standard parameters of cardiac chamber size and function, answers from the centres were homogeneous and demonstrated good adherence to current recommendations. In particular, all centres assessed left ventricular (LV) and left atrial (LA) size combining diameter measurements with volumes obtained using the bi-plane Simpson’s method. More variability was observed in the measurements of the right heart chambers and thoracic aorta. Interestingly, >90% of centres had access to 3DE and STE; however, the large majority of centres reserved the use of these techniques for selected cases, particularly for the measure of 3D LV volumes and ejection fraction and global longitudinal strain in patients being considered for cardiac device implantation, surgical intervention (valvular heart disease) or screened for cardiotoxicity. Only 10% of centres used 3DE for right ventricular and LA volumes. Also, <30% of the centres used LA strain imaging. ConclusionIn Europe, a good adherence to current recommendations was observed for most of the standard parameters of cardiac chambers quantification by TTE. Advanced echocardiography modalities, such as 3DE and STE, are widely available but used only in selected cases.

  • Derivation and validation of a mortality risk prediction model using global longitudinal strain in patients with acute heart failure
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-09
    Hwang I, Cho G, Choi H, et al.

    AimsTo develop a mortality risk prediction model in patients with acute heart failure (AHF), using left ventricular (LV) function parameters with clinical factors. Methods and resultsIn total, 4312 patients admitted for AHF were retrospectively identified from three tertiary centres, and echocardiographic parameters including LV ejection fraction (LV-EF) and LV global longitudinal strain (LV-GLS) were measured in a core laboratory. The full set of risk factors was available in 3248 patients. Using Cox proportional hazards model, we developed a mortality risk prediction model in 1859 patients from two centres (derivation cohort) and validated the model in 1389 patients from one centre (validation cohort). During 32 (interquartile range 13–54) months of follow-up, 1285 patients (39.6%) died. Significant predictors for mortality were age, diabetes, diastolic blood pressure, body mass index, natriuretic peptide, glomerular filtration rate, failure to prescribe beta-blockers, failure to prescribe renin–angiotensin system blockers, and LV-GLS; however, LV-EF was not a significant predictor. Final model including these predictors to estimate individual probabilities of mortality had C-statistics of 0.75 [95% confidence interval (CI) 0.73–0.78; P<0.001] in the derivation cohort and 0.78 (95% CI 0.75–0.80; P<0.001) in the validation cohort. The prediction model had good performance in both heart failure (HF) with reduced EF, HF with mid-range EF, and HF with preserved EF. ConclusionWe developed a mortality risk prediction model for patients with AHF incorporating LV-GLS as the LV function parameter, and other clinical factors. Our model provides an accurate prediction of mortality and may provide reliable risk stratification in AHF patients.

  • EuroCMR 2019 highlights
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-10
    Rodriguez-Palomares J, Edvardsen T, Almeida A, et al.

    Cardiovascular magnetic resonance (CMR) has become one of the main imaging techniques for the diagnosis and prognostic stratification of the different cardiovascular diseases. Proof of this is the growing interest in training in this imaging technique which was evident in the past EuroCMR 2019 where 1379 specialists (26.5% more than in the previous edition) met in Lido (Venice) to discuss the latest scientific advances in the CMR field. In this review, we will discuss the most recent research presented during this congress that aroused maximum interest.

  • The bicuspid aortic valve raphe: an evolving structure
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-06
    Yang L, Enriquez-Sarano M, Michelena H.

    A raphe between two fused cusps is visible in 50–88% in bicuspid aortic valve (BAV) by transthoracic echocardiogram (TTE) and the presence of raphe, particularly if calcified, is associated with early BAV degeneration and future development of aortic stenosis (AS). We describe two patients with right-left fusion BAV without visible raphe at diagnosis in the 1990s. A 33-year-old man with baseline TTE performed in 1994 (Panel A-left, Supplementary dataSupplementary data online, Video S1) had a ‘normally functioning’ BAV without raphe. Interval TTE in 2001 revealed a visible raphe and TTE 15 years from baseline (2009) revealed a calcified raphe in both systole and diastole (Panel A-right, arrows, Supplementary dataSupplementary data online, Video S2) with mild AS (mean systolic pressure gradient 17 mmHg).

  • Risk stratifying asymptomatic left ventricular systolic dysfunction in the community: beyond left ventricular ejection fraction
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-06
    Burocchi S, Gori M, Cioffi G, et al.

    AimsMidwall fractional shortening (MWFS) is a measure of left ventricular (LV) systolic function that is more reliable in case of concentric LV geometry compared to LV ejection fraction (LVEF). We hypothesized that MWFS might predict heart failure (HF) and death in a high-risk asymptomatic population, beyond other echocardiographic parameters. Methods and resultsAmong 4047 subjects aged ≥55/≤80 years followed by 10 general practitioners in northern Italy, the DAVID-Berg study prospectively enrolled 623 asymptomatic outpatients at increased risk for HF. Baseline evaluation included clinical visit, electrocardiogram, N-terminal pro-brain natriuretic peptide (NT-proBNP), and echocardiogram. Mean age of the population was 69 ± 7 years, 56% were men, 88% had hypertension, mean LVEF was 61 ± 9%, and mean MWFS 16.2 ± 3.3. During a median follow-up of 5.7 years, 95 subjects experienced HF/death events. At Cox analysis, lower MWFS was the only echocardiographic parameter, among structural/functional ones, associated with higher risk of HF/death [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.84–0.95, Padjusted < 0.001]. The risk of HF/death related to clinical data and NT-proBNP (baseline model) was reclassified by echocardiography only when MWFS was included into the model (baseline C-statistics 0.761; adding conventional structural/functional echocardiographic data 0.776, P = 0.09; adding MWFS 0.791, P = 0.007). Compared to subjects with normal LVEF and MWFS, only subjects with combined systolic dysfunction (11% of the population) were at higher risk (P = 0.001 for both abnormal; P > 0.24 for either LVEF or MWFS abnormal). Conclusion DAVID-Berg data suggest to include MWFS assessment in clinical practice, a simple and reliable echocardiographic parameter able to improve risk stratification in subjects at high risk for HF.

  • Pulmonary hypertension detection by computed tomography pulmonary transit time in heart failure with reduced ejection fraction
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-06
    Colin G, Pouleur A, Gerber B, et al.

    AimsTo evaluate the relationships between pulmonary transit time (PTT), cardiac function, and pulmonary haemodynamics in patients with heart failure with reduced ejection fraction (HFrEF) and to explore how PTT performs in detecting pulmonary hypertension (PH). Methods and resultsIn this prospective study, 57 patients with advanced HFrEF [49 men, 51 years ± 8, mean left ventricular (LV) ejection fraction 26% ± 8] underwent echocardiography, right heart catheterization, and cardiac computed tomography (CT). PTT was measured as the time interval between peaks of attenuation in right ventricle (RV) and LV and was compared between patients with or without PH and 15 controls. PTT was significantly longer in HFrEF patients with PH (21 s) than in those without PH (11 s) and controls (8 s) (P<0.001) but not between patients without PH and controls (P=0.109). PTT was positively correlated with pulmonary artery wedge pressure (PAWP) (r=0.74), mean pulmonary artery pressure (r=0.68), N-terminal pro-B-type natriuretic peptide (r=0.60), mitral (r=0.54), and tricuspid (r=0.37) regurgitation grades, as well as with LV, RV, and left atrial volumes (r from 0.39 to 0.64) (P<0.01). PTT was negatively correlated with cardiac index (r = −0.63) as well as with LV (r = −0.66) and RV (r = −0.74) ejection fractions. PAWP, cardiac index, mitral regurgitation grade, and RV end-diastolic volume were all independent predictors of PTT. PTT value ≥14 s best-detected PH with 91% sensitivity and 88% specificity (area under the receiver operating characteristic curve: 0.95). ConclusionIn patients with HFrEF, PTT correlates with cardiac function and pulmonary haemodynamics, is determined by four independent parameters, and performs well in detecting PH.

  • Physical activity and coronary artery calcification
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-12-04
    Kofoed K.

    This editorial refers to ‘Associations of recreational and non-recreational physical activity with coronary artery calcium density versus volume and cardiovascular disease events: the multi-ethnic study of atherosclerosis’ by I.C. Thomas et al., doi:10.1093/ehjci/jez271.

  • Predictive value of left ventricular diastolic chamber stiffness in patients with severe aortic stenosis undergoing aortic valve replacement
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-27
    Anand V, Adigun R, Thaden J, et al.

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

  • A mass in the pulmonary artery: the incremental value of cardiac magnetic resonance
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-27
    Qi Q, Chen Z, Zhou F, et al.

    A 44-year-old man with non-exercise-related chest pain was referred to our centre with the suspicion of pulmonary thromboembolism (PT). Transthoracic echocardiography of the aortic root in the short-axis view revealed that the pulmonary trunk was filled with a mass (heterogeneous echo signal), extending from the main pulmonary artery (MPA) to the left and right pulmonary arteries (LPA, RPA) (Panel A1). In addition, an ultrasound scan detected diffuse deep vein thrombosis (Panel A2). Pulmonary computed tomography angiography showed a large hypodense filling defect in the pulmonary arteries (Panel B1 and B2, Supplementary dataSupplementary data online, Video S1). To differentiate between thrombus and tumour, cardiovascular magnetic resonance (CMR) was performed to evaluate the tissue characteristics of the pulmonary mass. Sagittal view of steady-state free precession cine imaging showed that the lesion had unclear boundaries and poor mobility (Supplementary dataSupplementary data online, Video S2). On diffusion weighted imaging, the lesion appeared hyperintense (Panel C1) and the apparent diffusion coefficient value was 0.25 × 10−3 mm2/s. Fat-suppressed T2-weighted imaging revealed a heterogeneously hyperintense filling defect with an irregular proximal margin (Panel C2). On contrast-enhanced imaging, the lesion was shown to be heterogeneously enhanced (Panel C3). The tissue characteristics of the pulmonary mass on CMR imaging seemed to fit best with the diagnosis of a pulmonary intimal sarcoma (PIS) and exclude a PT. Subsequently, the patient underwent pulmonary artery resection and reconstruction (Panel D) followed by post-operative chemotherapy. Immunohistochemical analysis results were consistent with PIS (Panel E). The patient has no complaints and is still in remission.

  • An unexpected localization of papillary fibroelastoma
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-26
    Bohbot Y, Peugnet F, Delpierre Q, et al.

    An 81-year-old female patient with a history of permanent atrial fibrillation under Warfarin was admitted in our hospital for a transient ischaemic attack. All international normalized ratios for the past 6 months were in the therapeutic range. A transthoracic echocardiography was performed showing a mobile and voluminous mass attached to the basal interventricular septum (IVS) (Panel A). The transoesophageal echocardiography showed a bulky rounded mass attached to the basal IVS by a short peduncle with a highly mobile character (Supplementary data onlineSupplementary data online, Video S1) which was suggestive of a papillary fibroelastoma (PFE) (Panels B and C). The mass was measured at 14 × 5 mm (Panel D). Given the unusual location, we first suspected a tumour. Cardiac magnetic resonance was contraindicated because of an old pacemaker lead. A positron emission tomography scanner was performed to rule-out a malignant process and revealed no cardiac or extracardiac fixation. We decided to refer the patient for surgery which revealed a round mass attached to the basal IVS by a short single stalk. Immersed in water, the mass looked like a ‘sea anemone’ (Panel E, Supplementary data onlineSupplementary data online, Video S2). Pathology confirmed the diagnosis of PFE.

  • External compression of the right ventricular outflow tract caused by a malignant thymoma
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-26
    Karstensen K, Andersen N.

    A 62-year-old male patient with a pacemaker and previous bladder cancer was referred from his general practitioner due to macroscopic haematuria, weight-loss, and shortness of breath (function Class IIB).

  • Optical coherence tomography allows 3D reconstruction of ablation lesions
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-20
    Liang D, Arnold P, Roten L, et al.

    Radiofrequency catheter ablation (RFA) is an effective interventional treatment for atrial fibrillation. However, the immediate effect of RFA on the tissue is not directly visualized. This is a key limitation as only acute electrical measurements are taken into account and the atrial wall structure or ablation lesion form are neglected.

  • Image fusion of integrating fluoroscopy into 3D computed tomography in guidance of left atrial appendage closure
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-25
    Mo B, Wan Y, Alimu A, et al.

    Aims We evaluated the feasibility of left atrial appendage (LAA) closure guided by the image fusion of integrating fluoroscopy into 3D computed tomography (CT). Methods and results A total of 117 consecutive patients who underwent LAA closure with or without the image fusion were matched (1:2). Each LAA closure step of the Image fusion group was guided by the preprocedure CT and image fusion, especially in the plan of LAA measurement and transseptal puncture. All patients were successfully implanted with a WATCHMAN closure device. Comparing the two groups, the mean number of recapture times and the number of devices per patient of the Image fusion group were significantly lower (0.4 ± 0.5 vs. 0.7 ± 0.8, P = 0.031 and 1.0 ± 0.2 vs. 1.1 ± 0.3, P = 0.027, respectively). The one-time successful deployment rate by the support of the image fusion was higher than in the control group (66.7% vs. 44.9%, P = 0.026). Each case of the Image fusion group was completely occluded with one transseptal puncture, while five of the Non-image fusion group required redo transseptal punctures. During the 45-day follow-up, both group cases presented occlusion efficiency and no major adverse cardiac events were observed. Conclusion Image fusion technique integrating fluoroscopy into the 3D CT is safe and feasible which can be easily incorporated into the procedural work-flow of percutaneous LAA closure. The fusion image can play an important alternative role in the plan of LAA measurement and transseptal puncture site for improving the LAA closure procedure.

  • Increased rotational flow in the proximal aortic arch is associated with its dilation in bicuspid aortic valve disease
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-03-28
    Dux-Santoy L, Guala A, Teixidó-Turà G, et al.

    AimsAortic dilation in bicuspid aortic valve (BAV) might extend to the proximal arch. Arch flow dynamics and their relationship with this segment dilation are still unexplored. Using 4D-flow cardiovascular magnetic resonance, we analysed flow dynamics in the arch for each BAV morphotype and their association with this segment dilation. Methods and resultsOne hundred and eleven BAV patients (aortic diameters ≤55 mm, non-severe valvular disease), 21 age-matched tricuspid aortic valve (TAV) patients with dilated arch and 24 healthy volunteers (HV) underwent 4D-flow. BAV were classified per fusion morphotype: 75% right-left (RL-BAV), and per arch dilation: 57% dilated, mainly affecting the right-noncoronary (RN) BAV (86% dilated vs. 47% in RL-BAV). Peak velocity, jet angle, normalized displacement, in-plane rotational flow (IRF), wall shear stress, and systolic flow reversal ratio (SFRR) were calculated along the thoracic aorta. ANCOVA and multivariate linear regression analyses were used to identify correlates of arch dilation. BAV had higher rotational flow and eccentricity than TAV in the proximal arch. Dilated compared with non-dilated BAV had higher IRF being more pronounced in the RN-morphotype. RN-BAV, IRF, and SFRR were independently associated with arch dilation. Aortic stenosis and male sex were independently associated with arch dilation in RL-BAV. Flow parameters associated with dilation converged to the values found in HV in the distal arch. ConclusionIncreased rotational flow could explain dilation of the proximal arch in RN-BAV and in RL-BAV patients of male sex and with valvular stenosis. These patients may benefit from a closer follow-up with cardiac magnetic resonance or computed tomography.

  • Comparison of intra-procedural vs. post-stenting prolonged bivalirudin infusion for residual thrombus burden in patients with ST-segment elevation myocardial infarction undergoing: the MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and angioX) OCT study
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-03-28
    Garcia-Garcia H, Picchi A, Sardella G, et al.

    AimsTo compare prolonged bivalirudin infusion vs. an intra-procedural only bivalirudin infusion administration in subjects with ST-segment elevation myocardial infarction (STEMI) regarding residual stent strut thrombosis. Methods and resultsMultivessel STEMI patients undergoing primary percutaneous coronary intervention (PPCI) and scheduled for a staged percutaneous coronary intervention (PCI) before hospital discharge were selected among those allocated to either prolonged bivalirudin or intra-procedural only bivalirudin infusion in the MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and angioX) Treatment-Duration study. Optical coherence tomography (OCT) of the infarct-related artery was performed at the end of PPCI and 4–5 days thereafter during staged intervention. The predefined endpoint was the percentage difference in the number of stent cross-sections with a thrombotic area >5% at the end of PPCI and at the time of staged PCI (ΔThCS). Between September 2013 and November 2015, 137 were randomized to either intra-procedural only bivalirudin infusion (N = 64) or prolonged bivalirudin (N = 73) at 16 European sites. Mean stent area, minimum lumen area, percentage of malapposed struts, and mean percent thrombotic area were comparable after index or staged PCI. The difference in the proportion of frames with percent thrombotic area >5% (ΔTh > 5%) were −7.7 (−22.1 to 5.1) in the intra-procedural bivalirudin infusion group and −8.8 (−23.1 to 2.6) in the prolonged infusion group (P = 0.994). Time from index to follow-up OCT imaging and the infarct vessel artery did not affect this OCT-based endpoint. ConclusionA strategy of prolonged bivalirudin infusion after PPCI did not reduce residual stent strut thrombosis when compared with intra-procedural only bivalirudin infusion administration (funded by The Medicines Company and Terumo; MATRIX ClinicalTrials.gov number, NCT01433627).

  • Prognostic implications of global, left ventricular myocardial work efficiency before cardiac resynchronization therapy
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-05-25
    van der Bijl P, Vo N, Kostyukevich M, et al.

    AimsCardiac resynchronization therapy (CRT) restores mechanical efficiency to the failing left ventricular (LV) by resynchronization of contraction. Global, LV myocardial work efficiency (GLVMWE) can be quantified non-invasively with echocardiography. The prognostic implication of GLVMWE remains unexplored, and we therefore related GLVMWE before CRT to long-term prognosis. Methods and resultsData were analysed from an ongoing registry of patients with Class I indications for CRT. GLVMWE was defined as the ratio of constructive work in all LV segments, divided by the sum of constructive and wasted work in all LV segments, as a percentage. It was derived from speckle tracking strain echocardiography and non-invasive blood pressure measurements, taken pre-CRT. Patients were dichotomized according to baseline, median GLVMWE [75%; interquartile range (IQR) 66–81%]. A total of 153 patients (66 ± 10 years, 72% male, 48% ischaemic heart disease) were analysed. After a median follow-up of 57 months (IQR 28–76 months), 31% of patients died. CRT recipients with less efficient baseline energetics (GLVMWE <75%) demonstrated lower event rates than patients with more efficient baseline energetics (GLVMWE ≥75%) (log-rank test, P = 0.029). On multivariable analysis, global LV wasted work ratio <75% pre-CRT was independently associated with a decreased risk of all-cause mortality (hazard ratio 0.48, 95% confidence interval 0.25–0.92; P = 0.027), suggesting that the potential for improvement in LV efficiency is important for CRT benefit. ConclusionGLVMWE can be derived non-invasively from speckle tracking strain echocardiography and non-invasive blood pressure recordings. A lower GLVMWE before CRT is independently associated with improved long-term outcome.

  • Primary malignant peripheral nerve sheath tumour of the pericardium
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-05-18
    Lee J, Lee S, Kim W.

    A 73-year-old woman presented with dyspnoea for 6 months. Echocardiogram (Panel A) and chest computed tomography (CT, Panel B) revealed a large mass (asterisks) encasing the anterolateral side of left ventricle (LV) with partial loss of epicardial fat echodensity (white arrows) and pericardial effusion. Cardiac CT (Panel C) and conventional angiography (CAG) (Panel D) demonstrated a heterogeneously enhanced mass measuring 6.0 × 4.7 × 4.0 cm and total occlusion of the middle left anterior descending artery (LAD, arrowheads) with heavy calcification. Cardiac magnetic resonance imaging (Panel E) revealed a mass with unenhanced central necrosis and perfusion defect in the LAD territory (black arrow). 18F-fluorodeoxyglucose positron emission tomography CT (Panel F) showed a hypermetabolic pericardial mass invading adjacent myocardium and small lung nodules. CT-guided biopsy (Panels G–I) revealed the diagnosis of primary malignant peripheral nerve sheath tumour (MPNST) of the pericardium with positivity for S100 (Panel H) and vimentin (Panel I). She had refused surgical intervention and received palliative chemotherapy but experienced aggravating dyspnoea after 7 months. Echocardiogram, CT, and CAG (Panels J–L) showed increased tumour size up to 9.7 cm, further myocardial invasion, depressed LV ejection fraction of 25%, embedded LAD in the tumour and progression of the occlusion to the proximal LAD.

  • Imaging in patients with severe mitral annular calcification: insights from a multicentre experience using transatrial balloon-expandable valve replacement
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-04-09
    Praz F, Khalique O, Lee R, et al.

    AimsTo investigate valve sizing and the haemodynamic relevance of the predicted left ventricular outflow tract (LVOT) in patients with mitral annular calcification (MAC) undergoing transatrial transcatheter valve implantation (THV). Methods and resultsIn total, 21 patients undergoing transatrial THV, multiplanar reconstruction (MPR), maximum intensity projection (MIP), and cubic spline interpolation (CSI) were compared for MA sizing during diastole. In addition, predicted neo-LVOT areas were measured in 18 patients and correlated with the post-procedural haemodynamic dimensions. The procedure was successful in all patients (100%). Concomitant aortic valve replacement was performed in eight patients (43%) (AVR group). Sizing using MPR and MIP yielded comparable results in terms of area, perimeter, and diameter, whereas the dimensions obtained with CSI were systematically smaller. The simulated mean systolic neo-LVOT area was 133.4 ± 64.2 mm2 with an anticipated relative LVOT area reduction (neo-LVOT area/LVOT area × 100) of 59.3 ± 14.7%. The systolic relative LVOT area reduction, but not the absolute neo-LVOT area, was found to predict the peak (r = 0.69; P = 0.002) and mean (r = 0.65; P = 0.004) post-operative aortic gradient in the overall population as well as separately in the AVR (peak: r = 0.91; P = 0.002/mean: r = 0.85; P = 0.002) and no-AVR (peak: r = 0.89; P = 0.003/mean: r = 0.72; P = 0.008) groups. ConclusionIn patients with severe MAC undergoing transatrial transcatheter valve implantation, MPR, and MIP yielded comparable annular dimensions, while values obtained with CSI tended to be systematically smaller. Mitral annular area and the average annular diameter appear to be reliable parameters for valve selection. Simulated relative LVOT reduction was found to predict the post-procedural aortic gradients.

  • A challenging mitral valve anatomy for percutaneous repair with MitraClip: cleft posterior leaflet
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-06-25
    Melillo E, Ancona F, Buzzatti N, et al.

    A 66-year-old man with a history of ischaemic cardiomyopathy and heart failure was referred to our institute for worsening shortness of breath (New York Heart Association III) and orthopnoea. Transoesophageal echocardiography (TOE) showed severe functional mitral regurgitation (MR; 3D EROA 80 mm2) with a centromedial origin of the regurgitant jet, a cleft posterior leaflet between scallop P2–P3 and a spotty fibrocalcific lesion on the distal body of the anterior leaflet (scallop A2) (Panels A–D, Supplementary dataSupplementary data online, Video S1). After Heart Team discussion a MitraClip (Abbott Vascular, Santa Clara, CA, USA) procedure was planned. A first clip (XTR) was placed in central position with a slight clockwise rotation, just to the left of the cleft on the posterior leaflet, avoiding the fibrocalcific spot on the anterior leaflet (Panel E), with a successful grasping and moderate residual MR from the cleft (Panel F). Considering the reduced and distorted shape of the posteromedial orifice deriving from the non-parallel placement of the first clip, a second smaller clip (NTR) was implanted just medially to the cleft, with counterclockwise rotation (Panel G, Supplementary dataSupplementary data online, Video S2), resulting in a successful first-attempt grasping with trivial residual MR (Panels H and I, Supplementary dataSupplementary data online, Video S3).

  • Aorta-right atrium tunnel: an unexpected diagnosis
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-06-10
    Fontes A, Dias-Ferreira N, Ladeiras-Lopes R, et al.

    An asymptomatic 52-year-old woman was referred for the evaluation of a 4/6 continuous murmur in the right parasternal border. Patient had no relevant family history of congenital heart disease. The electrocardiogram showed sinus rhythm and the echocardiogram revealed a round, vascular communication from the left aortic sinus (LAS) to the right atrium (RA), with continuous turbulent flow on Doppler evaluation. Additionally, a cardiac computed tomography angiography was performed for better delineation of coronary and extra-cardiac anatomy. 3D volume rendered reconstructions showed a large and tortuous ‘tunnel-like’ structure arising from the LAS, coursing posteriorly to the aortic root and terminating in the roof of the RA, just inferior and medial to the superior vena cava junction (Panel A). The left anterior descending (LAD) and the circumflex (LCX) arteries arose independently from the proximal portion of the tunnel. Cardiac magnetic resonance imaging with phase-contrast cine (PC-MRI) showed non-dilated right ventricle (RV), right ventricular outflow tract (RVOT) or main pulmonary artery (MPA) and there were no signs of pressure or volume overload (Panels B–E and Supplementary dataSupplementary data online, Video S1). The Qp:Qs ratio assessed by PC-MRI was 1.8 (Panels F–I). The shunt volume assessed by in-plane PC-MRI was 37 mL, and this result was comparable to the difference between the pulmonary (PA) and aortic (Ao) flow (Qp–Qs = 40 mL). Once the patient was asymptomatic and there were no signs of right overload, we decided to manage the patient conservatively with close follow-up.

  • Ineffective inferior vena cava filter insertion: a pitfall in a patient with duplicated inferior vena cava
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-06-03
    Nakao Y, Higashi H, Nishimura K, et al.

    An 18-year-old man with no significant past medical history presented to our hospital complaining of syncope during stair-climbing. Contrast-enhanced computed tomography (CT) showed a large amount of pulmonary emboli (Panel A, arrows). In addition, we made a diagnosis of residual deep vein thrombosis (DVT) in the left common iliac vein (Panel B, arrow). As the patient had experienced a syncopal event and the large DVT remained, we decided to insert an inferior vena cava (IVC) filter into the IVC via the right internal jugular vein to prevent fatal pulmonary thromboembolism. Anticoagulant therapy with rivaroxaban (30 mg/day) was also initiated. Detailed analysis of the coagulation system revealed his protein S activity was reduced to 34%. Thus, protein S deficiency was diagnosed as the cause of the pulmonary thromboembolism and DVT.

  • Pulmonary arteriovenous malformations and embolic myocardial infarction identified with cardiovascular magnetic resonance
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-06-26
    Nazir M, Ismail T, Plein S, et al.

    A 42-year-old female developed central chest pain radiating to the left shoulder. Twelve lead electrocardiogram demonstrated no ischaemia and the serum troponin was raised at 28 (normal <13 ng/L), which peaked to 140 and fell to 67. Dual antiplatelet therapy with aspirin and clopidogrel was commenced for a presumed acute coronary syndrome. Transthoracic echocardiography demonstrated preserved biventricular function and mild mitral regurgitation (Supplementary data online, Movies S1 and S2Supplementary data online, Movies S1 and S2). Invasive coronary angiography demonstrated unobstructed coronary arteries and no coronary atheroma (Supplementary data online, Movies S3, S4 and S5Supplementary data online, Movies S3, S4 and S5). A cardiovascular magnetic resonance (CMR) scan was arranged to investigate aetiology of the clinical presentation.

  • Relationship between epicardial adipose tissue and coronary vascular function in patients with suspected coronary artery disease and normal myocardial perfusion imaging
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-07-13
    Nappi C, Ponsiglione A, Acampa W, et al.

    AimsWe evaluated the relationship between epicardial adipose tissue (EAT) and coronary vascular function assessed by rubidium-82 (82Rb) positron emission tomography/computed tomography (PET/CT) in patients with suspected coronary artery disease (CAD). Methods and resultsThe study population included 270 patients with suspected CAD and normal myocardial perfusion at stress–rest 82Rb PET/CT. Coronary artery calcium (CAC) score and EAT volume were measured. Absolute myocardial blood flow (MBF) was computed in mL/min/ from the dynamic rest and stress imaging. Myocardial perfusion reserve (MPR) was defined as the ratio of hyperaemic to baseline MBF and it was considered reduced when <2. MPR was normal in 177 (65%) patients and reduced in 93 (35%). Patients with impaired MPR were older (P<0.001) and had higher CAC score values (P=0.033), EAT thickness (P=0.009), and EAT volume (P<0.001). At univariable logistic regression analysis, age, heart rate reserve (HRR), CAC score, EAT thickness, and EAT volume resulted significant predictors of reduced MPR, but only age (P=0.002), HRR (P=0.021), and EAT volume (P=0.043) were independently associated with reduced MPR, at multivariable analysis. In patients with CAC score 0 (n=114), a significant relation between EAT volume and MPR (P=0.014) was observed, while the relationship was not significant (P=0.21) in patients with CAC score >0 (n=156). ConclusionIn patients with suspected CAD and normal myocardial perfusion, EAT volume predicts hyperaemic MBF and reduced MPR, confirming that visceral pericardium fat may influence coronary vascular function. Thus, EAT evaluation has a potential role in the early identification of coronary vascular dysfunction.

  • Late presentation of right atrial diverticulum: surgical intervention might not be imperative
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-06-29
    Stefil M, Stefil S.

    An asymptomatic 61-year-old man was admitted due to new-onset atrial fibrillation incidentally detected upon mandatory occupational health assessment. A transthoracic echocardiogram (TTE) revealed an enlarged right atrium with volume 230 mL (Simpson’s uniplane method) and area 49 cm2; in subcostal view, the right atrium was shown to contain a membrane-like structure, longitudinally arranged, appearing to separate the right atrium into two compartments (Panel A). Tricuspid valve was structurally normal with no apical displacement (Supplementary dataSupplementary data online, Video S1); estimated systolic pulmonary pressure was normal (32 mmHg). Left ventricular ejection fraction was 58%, TAPSE 1.5 cm. Bubble study performed during transoesophageal echocardiography (TOE) showed the right atrium filled with contrast on either side of the membrane, suggestive of fenestrations (Panel B; Supplementary dataSupplementary data online, Video S2). TOE demonstrated patent foramen ovale and excluded the presence of thrombi in both atrial appendages. Cardiac magnetic resonance imaging (MRI) confirmed the diagnosis of right atrial diverticulum (Panels C–E; Supplementary dataSupplementary data online, Videos S3–S5). There was no compression of the right coronary artery as confirmed by computed tomography coronary angiography (Panel F; Supplementary dataSupplementary data online, Video S6). Sinus rhythm was recovered on direct current cardioversion, but this was not maintained. Repeat TTE at 6 months showed no change in right atrial size. The literature suggests that the usual course of action is surgical excision to prevent rupture, but this patient’s history of physically demanding occupations (previous air force parachutist, currently a miner) raises doubt over the necessity of operative treatment in this instance. The patient remains asymptomatic, on anticoagulant treatment and receives echocardiographic follow-up.

  • Strain-oriented strategy for guiding cardioprotection initiation of breast cancer patients experiencing cardiac dysfunction
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-07-21
    Santoro C, Esposito R, Lembo M, et al.

    AimsThis study assessed the impact of the strain-guided therapeutic approach on cancer therapy-related cardiac dysfunction (CTRCD) and rate of cancer therapy (CT) interruption in breast cancer. Methods and resultsWe enrolled 116 consecutive female patients with HER2-positive breast cancer undergoing a standard protocol by EC (epirubicine + cyclophosphamide) followed by paclitaxel + trastuzumab (TRZ). Coronary artery, valvular and congenital heart disease, heart failure, primary cardiomyopathies, permanent or persistent atrial fibrillation, and inadequate echo-imaging were exclusion criteria. Patients underwent an echo-Doppler exam with determination of ejection fraction (EF) and global longitudinal strain (GLS) at baseline and every 3 months during CT. All patients developing subclinical (GLS drop >15%) or overt CTRCD (EF reduction <50%) initiated cardiac treatment (ramipril+ carvedilol). In the 99.1% (115/116) of patients successfully completing CT, GLS and EF were significantly reduced and E/e′ ratio increased at therapy completion. Combined subclinical and overt CTRCD was diagnosed in 27 patients (23.3%), 8 at the end of EC and 19 during TRZ courses. Of these, 4 (3.4%) developed subsequent overt CTRCD and interrupted CT. By cardiac treatment, complete EF recovery was observed in two of these patients and partial recovery in one. These patients with EF recovery re-started and successfully completed CT. The remaining patient, not showing EF increase, permanently stopped CT. The other 23 patients with subclinical CTRCD continued and completed CT. ConclusionThese findings highlight the usefulness of ‘strain oriented’ approach in reducing the rate of overt CTRCD and CT interruption by a timely cardioprotective treatment initiation.

  • Pulmonary blood volume index as a quantitative biomarker of haemodynamic congestion in hypertrophic cardiomyopathy
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-08-29
    Ricci F, Aung N, Thomson R, et al.

    Aims The non-invasive assessment of left ventricular (LV) diastolic function and filling pressure in hypertrophic cardiomyopathy (HCM) is still an open issue. Pulmonary blood volume index (PBVI) by cardiovascular magnetic resonance (CMR) has been proposed as a quantitative biomarker of haemodynamic congestion. We aimed to assess the diagnostic accuracy of PBVI for left atrial pressure (LAP) estimation in patients with HCM. Methods and results We retrospectively identified 69 consecutive HCM outpatients (age 58 ± 11 years; 83% men) who underwent both transthoracic echocardiography (TTE) and CMR. Guideline-based detection of LV diastolic dysfunction was assessed by TTE, blinded to CMR results. PBVI was calculated as the product of right ventricular stroke volume index and the number of cardiac cycles for a bolus of gadolinium to pass through the pulmonary circulation as assessed by first-pass perfusion imaging. Compared to patients with normal LAP, patients with increased LAP showed significantly larger PBVI (463 ± 127 vs. 310 ± 86 mL/m2, P < 0.001). PBVI increased progressively with worsening New York Heart Association functional class and echocardiographic stages of diastolic dysfunction (P < 0.001 for both). At the best cut-off point of 413 mL/m2, PBVI yielded good diagnostic accuracy for the diagnosis of LV diastolic dysfunction with increased LAP [C-statistic = 0.83; 95% confidence interval (CI): 0.73–0.94]. At multivariable logistic regression analysis, PBVI was an independent predictor of increased LAP (odds ratio per 10% increase: 1.97, 95% CI: 1.06–3.68; P = 0.03). Conclusion PBVI is a promising CMR application for assessment of diastolic function and LAP in patients with HCM and may serve as a quantitative marker for detection, grading, and monitoring of haemodynamic congestion.

  • PM2.5 concentration in the ambient air is a risk factor for the development of high-risk coronary plaques
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-08-14
    Yang S, Lee S, Park J, et al.

    AimsWe aimed to investigate whether long-term exposure to particulate matter with an aerodynamic diameter <2.5 μm (PM2.5) in the ambient air is related to the development or growth of coronary plaques. Methods and resultsThis study involved 364 residents of Seoul, Korea, who underwent serial coronary computed tomographic angiography (CCTA) at an interval of ≥2 years. Each participant’s average concentration of residential PM2.5 between the two CCTAs was calculated. Primary endpoint was the development of high-risk plaque (HRP), defined as a plaque with low attenuation, spotty calcium, and positive remodelling. Secondary endpoints were the volume increase of total plaque and its component volume. Among those without HRP at baseline (n = 341), 20 patients developed HRP at follow-up CCTA, the residential PM2.5 concentration of which was significantly higher than those without HRP at follow-up (25.8 ± 2.0 vs. 25.0 ± 1.7 μg/m3 for patients with newly developed HRP vs. patients without HRP at follow-up; P = 0.047). An increase in PM2.5 concentration was associated with increased incidence of HRP at follow-up [adjusted hazard ratio (aHR) 1.62, 95% confidence interval (CI) 1.22–2.15, P < 0.001]. In a secondary analysis, the PM2.5 concentration was associated with an increased risk of the formation of either fibrofatty or necrotic core component in newly developed plaques (aHR 1.41, 95% CI 1.23–1.61, P < 0.001), and with a higher risk of total plaque volume progression in the pre-existing plaques (aHR 1.14, 95% CI 1.05–1.23, P = 0.002). ConclusionExposure to higher concentration of PM2.5 in the ambient air is significantly associated with the development of high-risk coronary plaques.

  • European Association of Cardiovascular Imaging expert consensus paper: a comprehensive review of cardiovascular magnetic resonance normal values of cardiac chamber size and aortic root in adults and recommendations for grading severity
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-09-23
    Petersen S, Khanji M, Plein S, et al.

    This consensus paper provides a framework for grading of severity of cardiovascular magnetic resonance (CMR) imaging-based assessment of chamber size, function, and aortic measurements. This does not currently exist for CMR measures. Differences exist in the normal reference values between echocardiography and CMR along with differences in methods used to derive these. We feel that this document will significantly complement the current literature and provide a practical guide for clinicians in daily reporting and interpretation of CMR scans. This manuscript aims to complement a recent comprehensive review of CMR normal value publications to recommend cut-off values required for severity grading. Standardization of severity grading for clinically useful CMR parameters is encouraged to lead to clearer and easier communication with referring clinicians and may contribute to better patient care. To this end, the European Association of Cardiovascular Imaging (EACVI) has formed this expert panel that has critically reviewed the literature and has come to a consensus on approaches to severity grading for commonly quantified CMR parameters.

  • EACVI survey on multimodality training in ESC countries
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-09-17
    Cameli M, Marsan N, D’Andrea A, et al.

    One of the missions of the European Association of Cardiovascular Imaging (EACVI) is ‘to promote excellence in clinical diagnosis, research, technical development, and education in cardiovascular imaging’. The future of imaging involves multimodality so each imager should have the incentive and the possibility to improve its knowledge in other cardiovascular techniques. This article presents the results of a 20 questions survey carried out in cardiovascular imaging (CVI) centres across Europe. The aim of the survey was to assess the situation of experience and training of CVI in Europe, the availability and organization of modalities in each centre and to ask for vision about potential improvements in CVI at national and European level.

  • The year 2018 in the European Heart Journal—Cardiovascular Imaging: Part II
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-09-17
    Cosyns B, Haugaa K, Gerber B, et al.

    European Heart Journal - Cardiovascular Imaging was launched in 2012 as a multimodality cardiovascular imaging journal. It has gained an impressive impact factor during its first 5 years and is now established as one of the top cardiovascular journals and has become the most important cardiovascular imaging journal in Europe. The most important studies from 2018 will be highlighted in two reports. Part I of the review has focused on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on cardiomyopathies, congenital heart diseases, valvular heart diseases, and heart failure.

  • Old wine in a new bottle: non-invasive quantitative evaluation of pulmonary congestion with pulmonary blood volume index by cardiac magnetic resonance
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-09-23
    Houard L, Cosyns B, Droogmans S.

    This editorial refers to ‘Pulmonary blood volume index as a quantitative biomarker of haemodynamic congestion in hypertrophic cardiomyopathy’, by F. Ricci et al., pp. 1368--1376.

  • 更新日期:2019-11-21
  • The air pollution constituent particulate matter (PM2.5) destabilizes coronary artery plaques
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-10-19
    Münzel T, Daiber A.

    This editorial refers to ‘PM2.5 concentration in the ambient air is a risk factor for the development of high-risk coronary plaques’, by S. Yang et al., pp. 1355--1364.

  • Strain as hallmark to prevent interruption of breast cancer therapy
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-10-09
    Bergler-Klein J.

    This editorial refers to ‘Strain-oriented strategy for guiding cardioprotection initiation of breast cancer patients experiencing cardiac dysfunction’ by C. Santoro et al., pp. 1345--1352.

  • Age is just a Number (but which one is it?)
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-20
    Mehta A, Shapiro M.

    This editorial refers to ‘Vascular age derived from coronary artery calcium score on the risk stratification of individuals with heterozygous familial hypercholesterolemia’, by M.H. Miname et al., doi: 10.1093/ehjci/jez280.

  • Left atrial cluster mass
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-20
    Coccina F, Angelucci D, Mereu M, et al.

    An 88-year old woman was admitted because of dyspnoea. History included ischaemic heart disease treated with coronary artery bypass surgery, permanent atrial fibrillation on anticoagulation, and permanent pacemaker implant. Laboratory examination revealed Troponin I 0.086 ng/mL (no significant change during time) and N-terminal pro-brain natriuretic peptide 11129 pg/mL. Electrocardiogram displayed atrial fibrillation. Chest X-ray did not show pulmonary congestion/oedema. Transthoracic echocardiogram showed a cluster mass in the left atrium prolapsing into the mitral valve [Panels A and B (LA, left atrium; LV, left ventricle), Supplementary dataSupplementary data online, Movies S1 and S2]. Thoracic computed tomography scan did not show extra-cardiac involvement. Consulting cardiac surgeon recommended urgent surgical resection. Various roundish neoplasms of about 2-cm diameter originating from the left auricle were detected and removed. At macroscopic examination, multiple whitish neoplasms of weak consistency were observed. Microscopic examination documented sparse areas of hyaline myxoma and Type AB thymoma composed of oval epithelial cells admixed with a large number of lymphocytes (Panel C); immunohistochemistry with cytokeratins (CKAE1/AE3) was positive on thymocytes (Panel D), that with CD3 showed a rich T-lymphocytic infiltrate (Panel E) and that with CD34 indicated positive vascular design in the absence of thymocytes staining (Panel F). Immunohistochemical panel excluded a vascular or a left atrial solitary fibrous tumour. Cells with multipotent differentiation capabilities have been reported within cardiac myxomas, or ectopic tissues, such as thymic rests, have also been described. To our knowledge, this is the first report describing a thymoma arising within an atypical atrial myxoma and giving rise to a cluster mass.

  • Revascularization therapy in stable ischaemic heart disease: Perfusion restores, why does outcome not?
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-18
    Knaapen P.

    This editorial refers to ‘Improved regional myocardial blood flow and flow reserve after coronary revascularization as assessed by serial15O-water positron emission tomography/computed tomography’, by T. Aikawa et al., doi:10.1093/ehjci/jez220.

  • Valvular calcification and risk of peripheral artery disease: the Multi-Ethnic Study of Atherosclerosis (MESA)
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-18
    Garg P, Buzkova P, Meyghani Z, et al.

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

  • Potential usefulness and clinical relevance of a novel left atrial filling index to estimate left ventricular filling pressures in patients with preserved left ventricular ejection fraction
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-18
    Braunauer K, Düngen H, Belyavskiy E, et al.

    AimsThe aim of this study was to examine the potential usefulness and clinical relevance of a novel left atrial (LA) filling index using 2D speckle-tracking transthoracic echocardiography to estimate left ventricular (LV) filling pressures in patients with preserved LV ejection fraction (LVEF). Methods and resultsThe LA filling index was calculated as the ratio of the mitral early-diastolic inflow peak velocity (E) over LA reservoir strain (i.e. E/LA strain ratio). This index showed a good diagnostic performance to determine elevated LV filling pressures in a test-cohort (n = 31) using invasive measurements of LV end-diastolic pressure (area under the curve 0.82, cut-off > 3.27 = sensitivity 83.3%, specificity 78.9%), which was confirmed in a validation-cohort (patients with cardiovascular risk factors; n = 486) using the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging criteria (cut-off > 3.27 = sensitivity 88.1%, specificity 77.6%) and in a specificity-validation cohort (patients free of cardiovascular risk factors, n = 120; cut-off > 3.27 = specificity 98.3%). Regarding the clinical relevance of the LA filling index, an elevated E/LA strain ratio (>3.27) was significantly associated with the risk of heart failure hospitalization at 2 years (odds ratio 4.3, 95% confidence interval 1.8–10.5), even adjusting this analysis by age, sex, renal failure, LV hypertrophy, or abnormal LV global longitudinal systolic strain. ConclusionThe findings from this study suggest that a novel LA filling index using 2D speckle-tracking echocardiography could be of potential usefulness and clinical relevance in estimating LV filling pressures in patients with preserved LVEF.

  • The impact of visceral and general obesity on vascular and left ventricular function and geometry: a cross-sectional magnetic resonance imaging study of the UK Biobank
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-13
    van Hout M, Dekkers I, Westenberg J, et al.

    Aims We aimed to evaluate the associations of body fat distribution with cardiovascular function and geometry in the middle-aged general population. Methods and results Four thousand five hundred and ninety participants of the UK Biobank (54% female, mean age 61.1 ± 7.2 years) underwent cardiac magnetic resonance for assessment of left ventricular (LV) parameters [end-diastolic volume (EDV), ejection fraction (EF), cardiac output (CO), and index (CI)] and magnetic resonance imaging for body composition analysis [subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT)]. Body fat percentage (BF%) was assessed by bioelectrical impedance. Linear regressions were performed to assess the impact of visceral (VAT) and general (SAT and BF%) obesity on cardiac function and geometry. Visceral obesity was associated with a smaller EDV [VAT: β −1.74 (−1.15 to −2.33)], lower EF [VAT: β −0.24 (−0.12 to −0.35), SAT: β 0.02 (−0.04 to 0.08), and BF%: β 0.02 (−0.02 to 0.06)] and the strongest negative association with CI [VAT: β −0.05 (−0.06 to −0.04), SAT: β −0.02 (−0.03 to −0.01), and BF% β −0.01 (−0.013 to −0.007)]. In contrast, general obesity was associated with a larger EDV [SAT: β 1.01 (0.72–1.30), BF%: β 0.37 (0.23–0.51)] and a higher CO [SAT: β 0.06 (0.05–0.07), BF%: β 0.02 (0.01–0.03)]. In the gender-specific analysis, only men had a significant association between VAT and EF [β −0.35 (−0.19 to −0.51)]. Conclusion Visceral obesity was associated with a smaller LV EDV and subclinical lower LV systolic function in men, suggesting that visceral obesity might play a more important role compared to general obesity in LV remodelling.

  • Bronchial arterial hypertrophy discovered by transthoracic echocardiography
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-12
    Pergolini A, Zampi G, Pontillo D, et al.

    A 65-year-old Caucasian woman underwent transthoracic echocardiography during a follow-up to monitor progression of a dilated ascending aorta. She was asymptomatic and her past medical history was remarkable only for allergic asthma.

  • Vascular age derived from coronary artery calcium score on the risk stratification of individuals with heterozygous familial hypercholesterolaemia
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-08
    Miname M, Bittencourt M, Pereira A, et al.

    AimsThe objective of this study was to evaluate if vascular age derived from coronary artery calcium (CAC) score improves atherosclerosis cardiovascular disease (ASCVD) risk discrimination in primary prevention asymptomatic heterozygous familial hypercholesterolaemia (FH) patients undergoing standard lipid-lowering therapy. Methods and resultsTwo hundred and six molecularly confirmed FH individuals (age 45 ± 14 years, 36% males, baseline LDL-cholesterol 6.2 ± 2.2 mmol/L; 239 ± 85mg/dL) were followed by 4.4 ± 2.9 years (median: 3.7 years, interquartile ranges 2.7–6.8). CAC measurement was performed, and lipid-lowering therapy was optimized according to FH guidelines. Vascular age was derived from CAC and calculated according to the Multi Ethnic Study of Atherosclerosis algorithm. Risk estimation based on the Framingham equations was calculated for both biological (bFRS) and vascular (vaFRS) age. During follow-up, 15 ASCVD events (7.2%) were documented. The annualized rate of events for bFRS <10%, 10–20%, and >20% was respectively: 8.45 [95% confidence interval (CI) 3.17–22.52], 23.28 (95% CI 9.69–55.94), and 28.13 (95% CI 12.63–62.61) per 1000 patients. The annualized rate of events for vaFRS <10%, 10–20%, and >20% was respectively: 0, 0, and 50.37 (95% CI 30.37–83.56) per 1000 patients. vaFRS presented a better discrimination for ASCVD events compared to bFRS 0.7058 (95% CI 0.5866–0.8250) vs. vaFRS 0.8820 (95% CI 0.8286–0.9355), P = 0.0005. ConclusionCAC derived vascular age can improve ASCVD risk discrimination in primary prevention FH subjects. This tool may help further stratify risk in FH patients already receiving lipid-lowering medication who might be candidates for further treatment with newer therapies.

  • Myocardial fibrosis in arrhythmogenic cardiomyopathy: a genotype–phenotype correlation study
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-08
    Segura-Rodríguez D, Bermúdez-Jiménez F, Carriel V, et al.

    AimsArrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a life-threatening entity with a highly heterogeneous genetic background. Cardiac magnetic resonance (CMR) imaging can identify fibrofatty scar by late gadolinium enhancement (LGE). Our aim is to investigate genotype–phenotype correlation in ARVC/D mutation carriers, focusing on CMR-LGE and myocardial fibrosis patterns. Methods and resultsA cohort of 44 genotyped patients, 33 with definite and 11 with borderline ARVC/D diagnosis, was characterized using CMR and divided into groups according to their genetic condition (desmosomal, non-desmosomal mutation, or negative). We collected information on cardiac volumes and function, as well as LGE pattern and extension. In addition, available ventricular myocardium samples from patients with pathogenic gene mutations were histopathologically analysed. Half of the patients were women, with a mean age of 41.6 ± 17.5 years. Next-generation sequencing identified a potential pathogenic mutation in 71.4% of the probands. The phenotype varied according to genetic status, with non-desmosomal male patients showing lower left ventricular (LV) systolic function. LV fibrosis was similar between groups, but distribution in non-desmosomal patients was frequently located at the posterolateral LV wall; a characteristic LV subepicardial circumferential LGE pattern was significantly associated with ARVC/D caused by desmin mutation. Histological analysis showed increased fibrillar connective tissue and intercellular space in all the samples. ConclusionDesmosomal and non-desmosomal mutation carriers showed different morphofunctional features but similar LV LGE presence. DES mutation carriers can be identified by a specific and extensive LV subepicardial circumferential LGE pattern. Further studies should investigate the specificity of LGE in ARVC/D.

  • Mitral cleft endocarditis presenting with confusion
    Eur. Heart J. Cardiovasc. Imaging (IF 5.260) Pub Date : 2019-11-11
    Lloyd E, Ionescu A.

    A 53-year-old lady was brought to the emergency department obtunded, agitated, and confused. She had been generally unwell for 1 week prior to admission with fever and lethargy. There had been no specific or localizing infective symptoms. She was clinically septic with a pyrexia of 39.3°C, had low a Glasgow Coma Scale score and altered neurology including bilateral up-going planters. She was admitted directly to the intensive care unit and managed for possible meningoencephalitis.

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