European Heart Journal - Cardiovascular Imaging最新文献

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.

Valvular heart disease (VHD) remains significantly underdiagnosed and undertreated. This review examines an artificial intelligence (AI)-enhanced 'spoke-hub-node' care model designed to improve the early detection, risk stratification, and treatment of VHD. In this model, AI tools-such as automated ECG interpretation, digital stethoscopes, and point-of-care ultrasound-facilitate decentralized screening and referral for cardiac imaging at the community level. During the transition from outpatient settings to tertiary care centres, AI-integrated echocardiography, cardiac tomography, and magnetic resonance imaging facilitate advanced diagnostic evaluation and inform procedural planning. We review emerging innovations that can enhance this model of care delivery-including unsupervised machine learning to uncover novel VHD phenotypes, generative AI for automated reporting, the use of digital twins to simulate interventions, and the integration of multiple AI agents to support heart team meetings. These advances are followed by the emerging use of AI in robotic transoesophageal and intracardiac echocardiography, as well as in fusion fluoroscopy imaging, to guide valve interventions. While outlining the challenges inherent in this rapidly evolving field, the review's central contribution is its vision to connect the continuum-from AI-enabled community screening to personalized, image-guided therapies at tertiary care centres-offering a scalable and equitable model for VHD care.

Aims: Left ventricular (LV) enlargement in chronic aortic regurgitation (AR) is commonly assessed using diameters and volumes. However, these measures are influenced by body size, sex, and age. The left-to-right ventricular end-diastolic volume ratio (LV/RV ratio), assessed by cardiac magnetic resonance imaging (CMR) and known to remain close to 1 in healthy individuals, could provide a more individualized marker of LV remodeling in chronic AR.

Methods and results: This bi-centre study included 258 patients with chronic AR (median age: 55 years, 18% women) who underwent echocardiography (Echo) and CMR. LV and RV volumes were measured from cine-CMR images. Associations between the LV/RV ratio, conventional LV measures, and significant AR, defined as Grades 3-4 on Echo or aortic regurgitant fraction (AR-RegFrac) ≥ 33% on CMR, were analysed using area under the curve (AUC) and logistic regression. The median LV/RV ratio was 1.5 [1.3-1.9], increased with AR severity (P < 0.001), and correlated more strongly with AR-RegFrac (r = 0.67; P < 0.001) than conventional LV measures. The LV/RV ratio identified significant AR with good accuracy (Echo, AUC 0.77; CMR, AUC 0.83). A threshold of 1.5 provided balanced sensitivity and specificity (Se 71-84%, Sp 77-75%), while 1.8 ruled in significant AR with high specificity (Sp 91% for both modalities). The LV/RV ratio did not vary significantly by age or sex and showed consistent performance across subgroups.

Conclusion: The LV/RV ratio is a reliable and individualized marker of LV remodeling in chronic AR. These findings support its potential role in clinical assessment and further evaluation in outcome studies.

Aims: Aortic regurgitation (AR) is a prevalent valvular disease. Cardiovascular magnetic resonance (CMR) imaging is emerging as an accurate and precise method for assessing AR. However, its role in guiding interventions and risk stratification for outcomes remains to be fully defined.

Objective: This systematic review and meta-analysis evaluate the predictive utility of CMR-derived AR fraction (ARF) in determining intervention timing and clinical outcomes.

Methods and results: A systematic search identified observational studies assessing CMR-derived ARF in AR prognostication. Hazard ratios (HRs) for intervention timing, mortality, and heart failure were pooled using a random-effects model. Study heterogeneity (I² statistic) was assessed, and publication bias was evaluated using a funnel plot. A total of 1235 studies were screened, with 12 meeting the inclusion criteria. Eight studies (n = 1996 patients) were included in the meta-analysis. ARF severity thresholds ranged from 30 to 43% (mean 33.7%). Follow-up ranged from 2 to 5.1 years. The pooled HR for clinic outcomes with an ARF > 33% was 4.12 (95% CI: 2.31-7.34, P value < 0.01). The highest reported HR was 24.59, while the lowest was 1.04. Studies demonstrated that a higher ARF correlates with an increased risk of adverse outcomes, supporting CMR as a key tool for risk stratification and intervention timing.

Conclusion: CMR-derived ARF is strongly predictive of clinical outcomes. ARF > 33% is associated with significantly increased risk, warranting its integration into clinical decision-making frameworks.

Sex differences in valvular heart disease (VHD) represent an emerging focus in cardiovascular imaging, with implications spanning aetiology, pathophysiology, chamber remodelling, and prognosis. This review aims to illustrate how multimodality imaging can be applied to address sex-specific differences in VHD, with the goal of improving disease grading, staging of extra-valvular cardiac damage, and risk stratification across the whole VHD spectrum.

Aims: Several factors, including device design, annulus size, and sizing strategies, influence transcatheter heart valve (THV) haemodynamic outcomes in patients with aortic stenosis (AS). This sub-study evaluates early (30-day) echocardiographic outcomes of the Myval, Sapien, and Evolut THV series, focusing on haemodynamic performance and valve durability.

Methods and results: The LANDMARK trial is a prospective, randomised, multicentre, open-label, non-inferiority trial comparing 384 patients implanted with Myval THV series to 384 receiving Sapien and Evolut THV series. Haemodynamic assessments followed Valve Academic Research Consortium-3 recommendations. At 30-day, haemodynamic device success rates were 85.9%, 77.8, and 85.4% for Myval, Sapien, and Evolut THV series, respectively (PMyval-Sapien = 0.03 and PMyval-Evolut = 0.98). Significant improvements in peak aortic flow velocity, pressure gradients, effective orifice area (EOA), Doppler velocity index (DVI), and cardiac indices were observed across all groups, except for unchanged left ventricular ejection fraction. Moderate prosthesis-patient mismatch (PPM) was less frequent with Myval THV series(11.3%) vs. Sapien THV series(21.8%), but higher than Evolut THV series (5.3%) (PMyval-Sapien = 0.0024, PMyval-Evolut = 0.0396), while severe PPM showed no significant differences (4.2% vs. 6.3% vs. 1.8%; PMyval-Sapien = 0.394, PMyval-Evolut = 0.2438). Rates of ≥ moderate paravalvular leak (PVL) were lower in Myval (3.5%), and Sapien (1.7%) compared with Evolut THV series (8.3%) (PMyval-Sapien = 0.3769, PMyval-Evolut = 0.0336). Myval THV series required minimal oversizing compared with Evolut THV series (P < 0.0001).

Conclusion: The Myval THV series demonstrates short-term haemodynamic performance comparable to Evolut THV series and superior to Sapien THV series. Including intermediate sizes minimizes oversizing, underscoring its potential as an alternative for TAVI patients. Long-term follow-up is necessary to confirm these findings.

Clinical trial registration: ClinicalTrials.gov: NCT04275726, EudraCT number 2020-000,137-40.