European Heart Journal - Cardiovascular Imaging最新文献

Aims: Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real-world practice across a healthcare system has not been previously reported.

Methods and results: Five thousand five hundred and three patients recruited across 32 UK NHS hospitals between 2018 and 2022, participating in the EVAREST/BSE-NSTEP prospective cohort study, with data on medical outcomes up to 2023 available from NHS England were included in the analysis. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions, and relevant cardiovascular diagnoses, based on Kaplan-Meier analysis and Cox proportional hazard ratios (HRs). Median follow-up was 829 days (interquartile range 224-1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction [HR 2.71, 95% confidence interval (CI) 1.73-4.24, P < 0.001] and a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.03, 95% CI 1.41-2.93, P < 0.001). Hazard ratios increased with ischaemic burden. A negative stress echocardiogram identified an event-free 'warranty period' of at least 5 years in patients with no prior history of coronary artery disease and 4 years for those with disease.

Conclusion: In real-world practice, the degree of myocardial ischaemia recorded by clinicians at stress echocardiography correctly categorizes risk of future events over the next 5 years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period.

Aims: Limited data exist on echocardiographic predictors of weaning from veno-arterial extracorporeal membrane oxygenation (V-A ECMO). We aimed to test the performance of different echocardiographic indices to predict weaning from V-A ECMO and free survival after weaning.

Methods and results: Observational study including patients with cardiogenic shock submitted to V-AECMO. Echocardiography was performed after V-AECMO placement and daily during the weaning trial to assess cardiac recovery. Echocardiography data after V-A ECMO implantation and during the last weaning trial before V-A ECMO removal were analysed. Besides traditional parameters, total isovolumic time (t-IVT, a left ventricular performance index) and mitral annular plane systolic excursion (MAPSE) were also tested. Seventy-six patients were included. A greater ventricular velocity time integral (LVOT VTI) at baseline was associated with a five-fold increase in weaning success (P < 0.001) as MAPSE lateral >6.15 mm (P = 0.001) did. TAPSE and S' at tricuspid annulus showed an analogous association. During the weaning trial t-IVT, LVEF, MAPSE, LVOT VTI, and TAPSE all improved significantly (P < 0.001 for all). At regression analysis t-IVT <14.4 s/min (<0.001), LVOT VTI >12.3 cm (P < 0.001), MAPSE > 8.9 mm (P < 0.001), TAPSE > 16 mm (<0.001), and E/e' < 15.5 (P = 0.001) were associated with weaning success and free survival after weaning. LVEF did not predict the weaning success and survival at any time-point (P = 0.230).

Conclusion: Longitudinal function, t-IVT and native ejection, measured with LVOT VTI, are reliable parameters to predict weaning success in V-A ECMO whereas the LVEF, although dynamically changing during weaning trial, it is not.

Aims: Sex-specific low flow was recently defined as stroke volume index (SVi) ≤ 40 mL/m² in men and ≤32 mL/m² in women. We tested the prognostic association of these cut-offs in patients with aortic stenosis (AS) with concordantly and discordantly graded AS [concordantly graded AS by energy loss (CGASEL) and discordantly graded AS by energy loss (DGASEL)] based on pressure recovery adjusted aortic valve area [energy loss (EL)].

Methods and results: Data from 1351 patients with asymptomatic AS, peak jet velocity <4 m/s, and preserved left ventricular ejection fraction enrolled in the Simvastatin and Ezetimibe in Aortic Stenosis study were used. DGASEL was defined as EL <1.0 cm² with mean aortic gradient <40 mmHg and CGASEL as EL ≥1.0 cm² with mean aortic gradient <40 mmHg. Patients were further grouped into normal and low flow. The outcome was combined all-cause death and hospitalization for heart failure (HF). CGASEL with normal/low flow was present in 915/253 patients, and DGASEL with normal/low flow was present in 57/126 patients. During a median follow-up of 4.3 years, event-free survival was lower in patients with DGASEL irrespective of flow compared to CGASEL with normal flow (P < 0.05). In Cox regression analysis, DGASEL with normal or low flow were both associated with increased risk of all-cause death and hospitalization for HF after adjustment for age, sex, heart rate, randomized study treatment, hypertension, aortic valve replacement, and aortic valve calcification (P < 0.05). No survival difference was found between patients with normal vs. low flow within groups of DGASEL or CGASEL.

Conclusion: Identification of low flow by the proposed sex-specific thresholds of SVi needs more prognostic validation before application in clinical practice.

Clinicaltrials.gov identifier: NCT00092677.

Aims: The diagnostic performance of quantitative perfusion cardiac magnetic resonance (QP-CMR) imaging has scarcely been evaluated in patients with a history of coronary artery disease (CAD) and new onset chest pain. The present study compared the diagnostic performance of automated QP-CMR for the detection of fractional flow reserve (FFR) defined hemodynamically significant CAD with visual assessment of first-pass stress perfusion CMR (v-CMR) and quantitative [15O]H2O positron emission tomography (PET) imaging in a true head-to-head fashion in patients with prior CAD.

Methods and results: This PACIFIC-2 substudy included 145 symptomatic chronic coronary symptom patients with prior myocardial infarction and/or percutaneous coronary intervention. All patients underwent dual-sequence, single-bolus perfusion CMR, and [15O]H2O PET perfusion imaging followed by invasive coronary angiography with three-vessel FFR. Hemodynamically significant CAD was defined as an FFR ≤ 0.80. QP-CMR, v-CMR, and PET exhibited a sensitivity of 66, 67, and 80%, respectively, whereas specificity was 60, 62, and 63%. Sensitivity of QP-CMR was lower than that of PET (P = 0.015), whereas the specificity of QP-CMR and PET was comparable. Diagnostic accuracy and area under the curve of QP-CMR (64% and 0.66) was comparable to both v-CMR [66% (P = not significant [NS]) and 0.67 (P = NS)] and PET [74% (P = NS) and 0.78 (P = NS)].

Conclusion: In patients with prior myocardial infarction and/or percutaneous coronary intervention, the diagnostic performance of QP-CMR was comparable to visual assessment of first-pass stress perfusion CMR and quantitative [15O]H2O PET for the detection of hemodynamically significant CAD as defined by FFR.

Aims: The relative apical sparing pattern of left ventricular (LV) longitudinal strain (RELAPS > 1) has been described as a typical sign of cardiac amyloidosis (CA). The objective was to validate this pattern in concomitant CA and aortic stenosis (AS) and to identify new echocardiographic variables suggestive of CA in the presence of AS.

Methods and results: Three hundred and twenty-four consecutive patients (age 81.5 ± 5.8 years, 51% women) with AS who underwent transcatheter aortic valve implantation (TAVI) were prospectively included. 2D speckle tracking echocardiography was performed. Following TAVI, 99mTc-DPD scintigraphy and protein electrophoresis were performed to screen for CA. Thirty-eight patients (11.7%) showed cardiac uptake in scintigraphy: 14 patients (4.3%) with Grade 1, 13 (4%) with Grade 2, and 11 (3.4%) with Grade 3. Patients with Grades 2 and 3 (AS-CA group) had more LV hypertrophy (LV mass index: 188 vs. 172 g/m2, P = 0.032), lower transvalvular aortic pressure gradient (P < 0.003), and higher prevalence of low-gradient AS (50% vs. 19%, P = 0.001), as well as greater diastolic and systolic dysfunction. Strain analysis was limited to 243 patients due to poor acoustic window and restrictions imposed by the COVID-19 pandemic (81 lost: 79 in AS alone, 1 each in AS-DPD1 and AS-CA groups). RELAPS > 1 was more prevalent in AS-CA group (74% vs. 44%, P = 0.006). An echocardiographic prediction model (GRAM score) for CA in the presence of AS, which is more sensitive and specific than RELAPS > 1 alone, is proposed using the LV mass, maximum aortic gradient, and RELAPS > 1, in addition to age (area under the curve: 0.85, 95% confidence interval: 0.77-0.93).

Conclusion: RELAPS > 1 is more prevalent in AS-CA but can occur in almost half of AS patients without CA, which reduces its value as a screening tool. A more sensitive and specific prediction score for CA in patients with severe AS is proposed.

Aims: Low-gradient (LG) aortic stenosis (AS) poses a diagnostic challenge. Aortic valve calcium score (AVCS) assessment has emerged as a complementary diagnostic method when echocardiography provides discordant results. However, the diagnostic and prognostic values of AVCS in LGAS have not been thoroughly studied. Our aims in this study were to investigate the prognostic importance of AVCS in LGAS and to assess whether symptomatic patients with LGAS and low AVCS may benefit from aortic valve intervention (AVI).

Methods and results: A total of 327 symptomatic patients (78.5 ± 7.3 years, 51% women) with severe AS defined by the aortic valve area who underwent computed tomography for transcatheter aortic valve intervention (TAVI) planning were enrolled. AVCS was measured. AVCS < 2000AU in men and < 1200 AU in women was considered a low AVCS. A total of 243 patients had high gradient (HG) and 84 had LGAS. A low AVCS was present in 25 (10%) patients with HG and 34 (40%) with LGAS. Over a median follow-up period of 4.9 years, 194 deaths occurred. In multivariate analysis, AVCS was a significant independent predictor of all-cause mortality among patients with HGAS [adjusted hazard ratio (aHR): 2.317; CI: 1.104-4.861; P = 0.026] but not among those with LGAS (aHR: 0.848; CI: 0.434-1.658; P = 0.630). After propensity score matching between patients who underwent AVI and those who were medically treated, AVI (94% TAVI) was a significant and independent predictor of survival among LGAS patients with a low AVCS even after adjustment for clinical variables (aHR: 0.102, CI: 0.028-0.369; P < 0.001).

Conclusion: The prevalence of a low AVCS is much higher in patients with LGAS than in those with HGAS. In patients with symptomatic severe LGAS, a low AVCS does not entail a better prognosis. AVI is equally beneficial in LGAS patients with a high or low AVCS, similarly to those with HGAS.