European Heart Journal - Cardiovascular Imaging最新文献

Valvular heart disease (VHD) is traditionally assessed through gradients, regurgitant volumes, and ejection fraction-but these valve-centric indices miss the earliest and most decisive signal: myocardial injury. Contemporary evidence shows that VHD is a myocardial disease, where outcomes are driven far more by the ventricle's biological response than by the valve lesion itself. This state-of-the-art review redefines VHD through a myocardium-first lens, highlighting tools that expose dysfunction long before conventional thresholds fail. A focused triad-LV global longitudinal strain (LV-GLS), RV strain with RV-PA coupling, and LA reservoir strain-detects injury at its inception and sharply improves prognostic precision. Cardiac magnetic resonance adds mechanistic depth through native T1, extracellular volume, and late gadolinium enhancement, identifying diffuse and focal fibrosis that dictate timing and reversibility of remodelling. Next-generation technologies extend this paradigm: CT-derived ECV as a scalable fibrosis surrogate, molecular imaging revealing active calcification and fibro-inflammation, and AI-driven models that fuse imaging, biomarkers, and clinical variables into personalized risk trajectories. We propose a serial, multiparametric, AI-enhanced strategy centred on myocardial protection-using LV-GLS tracking, RV-PA coupling, atrial mechanics, and fibrosis imaging to intervene during the true therapeutic window. This review positions a simple but transformative concept: managing VHD means managing the myocardium. Adopting this shift is essential for preserving cardiac health-not merely correcting valve anatomy.

Aims: Research has shown that the corrected proximal isovelocity surface area (PISA) method yields larger values for regurgitant volume (RegVol) and effective regurgitant orifice area (EROA) than conventional PISA method. However, it remains unclear whether new threshold values are needed for the corrected PISA method to effectively categorize the severity of secondary tricuspid regurgitation (STR). This study sought to identify threshold values for EROA and RegVol measured by the corrected PISA method for a three-grade classification of STR severity.

Methods and results: We used three-dimensional echocardiography to determine the volumetric regurgitant fraction (RegFr), calculated as the difference between the right (RV) and left ventricular (LV) stroke volumes (SV) divided by the RVSV. A total of 213 patients (78 ± 10 years; 64% women) with isolated STR were enrolled. Based on RegFr, we classified STR severity into mild (RegFr < 16%), moderate (RegFr 16-49%), and severe (RegFr > 49%) grades. EROA and RegVol were measured using conventional (EROACONV, RegVolCONV) and corrected (EROACORR, RegVolCORR) PISA methods. The threshold values for identifying patients with mild, moderate, and severe STR were <0.22, 0.22-0.46, and >0.46 cm² for EROACORR, respectively; and <18, 18-42, and >42 mL for RegVolCORR, respectively. The accuracy of these new threshold values in predicting STR severity based on RegFr was 99% for EROACORR and 94% for RegVolCORR. These accuracies were significantly higher than those of EROACONV (90%, P < 0.001) and RegVolCONV (41%, P < 0.001).

Conclusion: New threshold values for the corrected PISA method must be considered to improve the classification of STR severity.

Aims: This study aims to investigate the prognostic role of Stage 3 and 4 cardiac damage (CD) after transcatheter aortic valve intervention (TAVI), dependent on whether comorbidities contributing to right heart dysfunction were present.

Methods and results: Patients with severe aortic stenosis (AS) undergoing TAVI were included. Patients were divided into three groups: Stage 0-2 CD; Stage 3-4 CD, isolated AS (Stage 3-4 CD without significant concomitant chronic obstructive pulmonary disease, mitral annular calcification, mitral stenosis, mitral regurgitation, previous coronary artery bypass graft surgery, or cardiac amyloidosis); Stage 3-4 CD, AS with comorbidities (Stage 3-4 CD with ≥ 1 of these comorbidities). Futility was defined as death or Stage 3-4 New York Heart Association class dyspnoea 1 year after TAVI.Of 985 included patients, 822 (83%) had Stage 1-2 CD; 101 (10%) had Stage 3-4 CD, isolated AS; and 62 (6%) had Stage 3-4 CD, AS with comorbidities. Futility was not more common in Stage 3-4 CD groups (Stage 1-2 CD, 10%; Stage 3-4 CD, isolated AS, 17%; Stage 3-4 CD, AS with comorbidities, 15%, P = 0.09). Baseline and 1-year NYHA class were higher in Stage 3-4 CD compared with Stage 1-2 CD (P < 0.01). The 6 min walking test distance increased similarly in all groups at 1 year.

Conclusion: Potential comorbidities contributing to right heart dysfunction were common among patients in Stage 3-4 CD undergoing TAVI. Stage 3-4 CD was not associated with a significantly higher risk of futility, irrespective of comorbidities, and they experienced a similar functional improvement after TAVI.

Aims: We sought to illustrate the varying risk of permanent pacemaker implantation (PPMI) following self-expanding TAVI among bicuspid aortic valve (BAV) subtypes, and to categorize BAV anatomical variations based on the risk of PPMI.

Methods and results: We retrospectively analyzed 300 BAV patients with severe aortic stenosis who underwent self-expanding TAVI. Based on leaflet morphology and calcification severity at the commissure between right coronary cusp (RCC) and non-coronary cusp (NCC), BAVs were classified into two subtypes: BAV with MS below commissure (BAV-MSBC) and BAV with MS below leaflet (BAV-MSBL). Univariate and multivariate logistic regressions were performed to identify potential risk factors of PPMI. PPMI rate differed significantly between BAV-MSBC and BAV-MSBL [32.8% (42 of 128) vs. 5.8% (10 of 172), P < 0.001]. Multivariate analysis identified BAV-MSBC [odds ratio (OR) = 10.15, 95% confidence interval (CI): 4.07-25.34, P < 0.001], previous AVB I (OR = 4.15, 95% CI: 1.32-13.04, P = 0.015) and right bundle branch block (OR = 26.39, 95% CI: 4.81-144.82, P < 0.001) as risk factors of PPMI, while △MSID-RCC (OR = 0.78, 95% CI: 0.70-0.86, P < 0.001) was protective. The multivariate model had an AUC of 0.887 (95% CI: 0.843-0.930).

Conclusion: PPMI risk differs significantly between BAV subtypes, possibly due to variations in MS proximity to the stent. The new BAV classification method may improve PPMI risk prediction and patient management.

Aims: Current guidelines lack sex-specific thresholds for assessing secondary tricuspid regurgitation (STR) severity and right ventricular (RV) and tricuspid annulus (TA) remodelling. We aimed to determine whether risk-based cut-offs for these parameters differ between men and women with STR.

Methods and results: We included 554 patients (74 ± 13 years, 51% women) with moderate or severe STR. The primary endpoint was all-cause mortality or heart failure hospitalization. Women were older (P < 0.001) and had a higher prevalence of atrial fibrillation (P = 0.008) and atrial STR (P < 0.001), whereas men more frequently had coronary artery disease (P < 0.001), chronic kidney disease (P = 0.005), and mitral regurgitation (P < 0.001). Women exhibited smaller RV and TA dimensions and higher RV ejection fraction (RVEF) (P < 0.001). Over a median follow-up of 19 (8-27) months, 230 patients reached the composite endpoint. Event-free survival at 2 years was comparable between sexes (P = 0.183), even after inverse propensity weighting (P = 0.342). Sex-specific thresholds for STR severity were lower in women for effective regurgitant orifice area (EROA) (0.36 cm² vs. 0.43 cm²) and regurgitant volume (RegVol) (31 mL vs. 35 mL) but higher for regurgitant fraction (46% vs. 39%). Women also exhibited comparable risk at lower RV end-diastolic (81 mL/m² vs. 96 mL/m²) and end-systolic volumes (37 mL/m² vs. 49 mL/m²), higher RVEF (49% vs. 41%), and smaller TA diameter (19 mm/m² vs. 22 mm/m²).

Conclusion: In STR, women face a similar risk at lower EROAs and RegVols, along with smaller RV volumes, higher RVEF, and reduced TA dimensions. These findings highlight the importance of incorporating sex-specific thresholds into clinical decision-making when assessing STR severity and right heart remodelling.