Pub Date : 2026-02-01DOI: 10.1016/j.jcmg.2025.09.011
Wissam Rahi MD , Hossam Lababidi MD , Imad Hussain MD, Miguel A. Quinones MD, Sherif F. Nagueh MD
Background
The H2FPEF score was developed for heart failure with preserved ejection fraction (HFpEF) diagnosis based on clinical parameters, septal E/e′ ratio and pulmonary artery systolic pressure. Diagnostic accuracy can be improved by additional echocardiographic parameters.
Objectives
This report aims to study the impact of echocardiography in improving the accuracy of The H2FPEF score, using the score as the initial step for HFpEF diagnosis.
Methods
Stable patients with ejection fraction ≥50% who underwent right heart catheterization and echocardiographic imaging within 30 days were included. H2FPEF score was computed. Echocardiographic measurements recommended in ASE (American Society of Echocardiography) 2025 diastolic function guidelines update were included.
Results
There were 511 patients with 237 having pulmonary capillary wedge pressure >15 mm Hg at rest or >25 mm Hg with exercise. Heart failure probability of <30% was present in 60 patients, whereas 58 had a probability of 30%-49%, 113 had a probability of 50%-80%, and 280 had a probability of >80%. Accuracy of The H2FPEF score was not improved with the addition of echocardiographic assessment when HF probability was <30% (P = 0.083). For all other probabilities, echocardiographic assessment significantly added to H2FPEF score accuracy. Net reclassification improvement was 1.38 (P < 0.001), and integrated discrimination improvement was 0.38 (P < 0.001).
Conclusions
The H2FPEF score has good accuracy in excluding HF diagnosis when HF probability based on the score is <30%. When probability is >30%, 2025 ASE diastolic function guidelines approach to the estimation of mean left atrial pressure adds to accuracy.
H2FPEF评分是基于临床参数、间隔E/ E比值和肺动脉收缩压来诊断保留射血分数（HFpEF）的心力衰竭。超声心动图附加参数可提高诊断准确性。目的本报告旨在研究超声心动图对提高H2FPEF评分准确性的影响，并将其作为诊断HFpEF的第一步。方法选取射血分数≥50%、30 d内行右心导管及超声心动图检查的稳定患者。计算H2FPEF评分。包括美国超声心动图学会（ASE） 2025舒张功能指南更新中推荐的超声心动图测量。结果511例患者中237例静息时肺毛细血管楔压>5 mm Hg，运动时bbb25 mm Hg。心力衰竭的概率为80%。当HF概率为30%时，超声心动图评估对H2FPEF评分的准确性没有提高，2025 ASE舒张功能指南方法对平均左房压的估计增加了准确性。
{"title":"Improving the Diagnosis of HFpEF","authors":"Wissam Rahi MD , Hossam Lababidi MD , Imad Hussain MD, Miguel A. Quinones MD, Sherif F. Nagueh MD","doi":"10.1016/j.jcmg.2025.09.011","DOIUrl":"10.1016/j.jcmg.2025.09.011","url":null,"abstract":"<div><h3>Background</h3><div>The H<sub>2</sub>FPEF score was developed for heart failure with preserved ejection fraction (HFpEF) diagnosis based on clinical parameters, septal E/e′ ratio and pulmonary artery systolic pressure. Diagnostic accuracy can be improved by additional echocardiographic parameters.</div></div><div><h3>Objectives</h3><div>This report aims to study the impact of echocardiography in improving the accuracy of The H<sub>2</sub>FPEF score, using the score as the initial step for HFpEF diagnosis.</div></div><div><h3>Methods</h3><div>Stable patients with ejection fraction ≥50% who underwent right heart catheterization and echocardiographic imaging within 30 days were included. H<sub>2</sub>FPEF score was computed. Echocardiographic measurements recommended in ASE (American Society of Echocardiography) 2025 diastolic function guidelines update were included.</div></div><div><h3>Results</h3><div>There were 511 patients with 237 having pulmonary capillary wedge pressure >15 mm Hg at rest or >25 mm Hg with exercise. Heart failure probability of <30% was present in 60 patients, whereas 58 had a probability of 30%-49%, 113 had a probability of 50%-80%, and 280 had a probability of >80%. Accuracy of The H<sub>2</sub>FPEF score was not improved with the addition of echocardiographic assessment when HF probability was <30% (<em>P =</em> 0.083). For all other probabilities, echocardiographic assessment significantly added to H<sub>2</sub>FPEF score accuracy. Net reclassification improvement was 1.38 (<em>P <</em> 0.001), and integrated discrimination improvement was 0.38 (<em>P <</em> 0.001).</div></div><div><h3>Conclusions</h3><div>The H<sub>2</sub>FPEF score has good accuracy in excluding HF diagnosis when HF probability based on the score is <30%. When probability is >30%, 2025 ASE diastolic function guidelines approach to the estimation of mean left atrial pressure adds to accuracy.</div></div>","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 166-174"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145357616","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.jcmg.2025.08.021
Davide Margonato MD , Bernardo B. Lopes MD , Go Hashimoto MD , Miho Fukui MD, PhD , Asa Phichaphop MD , Cheng Wang MD , Takahiro Nishihara MD , Ellen Cravero MS , Paul Sorajja MD , Vinayak Bapat MD , Maurice Enriquez-Sarano MD , João L. Cavalcante MD
Background
Anatomic regurgitant orifice area (AROA) can be measured by 4-dimensional (4D)–computed tomography angiography (CTA) to define tricuspid regurgitation (TR) severity, but its association with outcomes has not been established.
Objectives
This study aims to assess the independent prognostic value of TR quantification by 4D-CTA AROA measurement.
Methods
Comprehensive clinical, echocardiographic and 4D-CTA data were collected from patients with clinically significant TR evaluated at 4 Allina Health centers between 2019 and 2023 for TR intervention. The outcome of interest was all-cause mortality under medical management after diagnosis.
Results
AROA measurement was obtained in 174 patients (median age 83 years [Q1-Q3: 77- 97 years], left ventricular ejection fraction 58% [Q1-Q3: 51%-60%], right ventricular [RV] ejection fraction 46% [Q1-Q3: 41%-51%] and tricuspid AROA 0.74 cm2 [Q1-Q3: 0.55-1.42 cm2]). During a median follow-up of 2.3 years [Q1-Q3: 1.1-3.2 years], 49 (28%) patients died under medical management with 3-year survival rate of 55% [Q1-Q3: 45%-67%]. Spline curve analysis showed that AROA 1.1 cm2 was the threshold associated with increased mortality within the cohort. Patients with AROA ≥1.1 cm2 had higher TRI-SCOREs, larger tricuspid annulus dimension, tricuspid maximum coaptation gap, RV and right atrial volumes (all P < 0.001). Despite similar RV ejection fraction, patients with AROA ≥1.1 cm2 had worse RV function denoted by lower RV free-wall longitudinal strain (P < 0.001) compared to those with AROA <1.1 cm2. In multivariable analysis, AROA ≥1.1 cm2 remained independently associated with excess mortality (adjusted HR 2.23 [95% CI: 1.02-4.85]; P = 0.040) and worse 3-year survival under medical management (68% [Q1-Q3: 56%-82%] vs 36% [Q1-Q3: 28%-52%]; P = 0.013).
Conclusions
This first outcome study of patients with clinically significant TR examined by 4D-CTA shows that higher AROA measurement strongly associates with worse right heart remodeling and independently associates with excess mortality. Therefore, 4D-CTA, beyond anatomical assessment, provides prognostically relevant assessment of TR severity. Thus, AROA measurement should be considered in patients with TR evaluated by 4D-CTA.
{"title":"Tricuspid Anatomic Regurgitant Orifice Area by Cardiac Computed Tomography","authors":"Davide Margonato MD , Bernardo B. Lopes MD , Go Hashimoto MD , Miho Fukui MD, PhD , Asa Phichaphop MD , Cheng Wang MD , Takahiro Nishihara MD , Ellen Cravero MS , Paul Sorajja MD , Vinayak Bapat MD , Maurice Enriquez-Sarano MD , João L. Cavalcante MD","doi":"10.1016/j.jcmg.2025.08.021","DOIUrl":"10.1016/j.jcmg.2025.08.021","url":null,"abstract":"<div><h3>Background</h3><div>Anatomic regurgitant orifice area (AROA) can be measured by 4-dimensional (4D)–computed tomography angiography (CTA) to define tricuspid regurgitation (TR) severity, but its association with outcomes has not been established.</div></div><div><h3>Objectives</h3><div>This study aims to assess the independent prognostic value of TR quantification by 4D-CTA AROA measurement.</div></div><div><h3>Methods</h3><div>Comprehensive clinical, echocardiographic and 4D-CTA data were collected from patients with clinically significant TR evaluated at 4 Allina Health centers between 2019 and 2023 for TR intervention. The outcome of interest was all-cause mortality under medical management after diagnosis.</div></div><div><h3>Results</h3><div>AROA measurement was obtained in 174 patients (median age 83 years [Q1-Q3: 77- 97 years], left ventricular ejection fraction 58% [Q1-Q3: 51%-60%], right ventricular [RV] ejection fraction 46% [Q1-Q3: 41%-51%] and tricuspid AROA 0.74 cm<sup>2</sup> [Q1-Q3: 0.55-1.42 cm<sup>2</sup>]). During a median follow-up of 2.3 years [Q1-Q3: 1.1-3.2 years], 49 (28%) patients died under medical management with 3-year survival rate of 55% [Q1-Q3: 45%-67%]. Spline curve analysis showed that AROA 1.1 cm<sup>2</sup> was the threshold associated with increased mortality within the cohort. Patients with AROA ≥1.1 cm<sup>2</sup> had higher TRI-SCOREs, larger tricuspid annulus dimension, tricuspid maximum coaptation gap, RV and right atrial volumes (all <em>P <</em> 0.001). Despite similar RV ejection fraction, patients with AROA ≥1.1 cm<sup>2</sup> had worse RV function denoted by lower RV free-wall longitudinal strain (<em>P <</em> 0.001) compared to those with AROA <1.1 cm<sup>2</sup>. In multivariable analysis, AROA ≥1.1 cm<sup>2</sup> remained independently associated with excess mortality (adjusted HR 2.23 [95% CI: 1.02-4.85]; <em>P =</em> 0.040) and worse 3-year survival under medical management (68% [Q1-Q3: 56%-82%] vs 36% [Q1-Q3: 28%-52%]; <em>P =</em> 0.013).</div></div><div><h3>Conclusions</h3><div>This first outcome study of patients with clinically significant TR examined by 4D-CTA shows that higher AROA measurement strongly associates with worse right heart remodeling and independently associates with excess mortality. Therefore, 4D-CTA, beyond anatomical assessment, provides prognostically relevant assessment of TR severity. Thus, AROA measurement should be considered in patients with TR evaluated by 4D-CTA.</div></div>","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 197-207"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145373952","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.jcmg.2025.10.020
Morteza Naghavi MD , Nathan D. Wong PhD , Michael V. McConnell MD, MSEE , David J. Maron MD , Khurram Nasir MD , Claudia I. Henschke MD, PhD , David F. Yankelevitz MD , Zahi A. Fayad PhD , Rozemarijn Vliegenthart MD, PhD , Kim A. Williams Sr. MD , Roxana Mehran MD , Mathew Budoff MD , Daniel Berman MD , Jamal S. Rana MD, PhD , Prediman K. Shah MD , Robert A. Kloner MD, PhD , Jagat Narula MD, PhD , Philip Greenland MD , Valentin Fuster MD, PhD
Atherosclerotic cardiovascular disease (ASCVD), in particular atherosclerotic coronary artery disease (CAD), is the leading cause of death in the United States and globally. In the majority of ASCVD victims, the first sign is an acute event (heart attack or stroke) with a high fatality rate. It is widely accepted that most CAD deaths are preventable if asymptomatic at-risk patients are diagnosed and treated before the onset of clinical symptoms. In the past 30 years, numerous studies conclusively demonstrated that coronary artery calcium (CAC) imaging diagnoses patients with subclinical CAD and predicts adverse outcomes beyond conventional risk factors such as hyperlipidemia, hypertension, smoking, and diabetes. Current ASCVD prevention guidelines issued by U.S. cardiovascular professional societies recommend risk factor assessment to screen individuals who may be at risk, followed by CAC imaging in the borderline- and intermediate-risk categories to diagnose and quantify the severity of CAD to guide treatment. However, most payers do not follow these guidelines to cover CAC imaging requiring patients to pay out of pocket, resulting in underdiagnosis and failure to prevent costly cardiovascular events. In this statement, we elaborate on the diagnostic use of CAC imaging and call on health care providers, payers, and policymakers to follow the ASCVD prevention guidelines and provide coverage. Covering the appropriate diagnostic use of CAC will enable physicians to perform shared decision-making for the treatment of patients with asymptomatic CAD and personalize the intensity of the treatment based on the extent of CAD. Specifically, this statement focuses on the diagnostic role of CAC imaging rather than its potential as a universal screening test. Although there are rationales for population-wide screening, such an approach would require large-scale outcome studies and is beyond the scope of this paper.
{"title":"Coronary Artery Calcium (CAC) Imaging as a Diagnostic Test","authors":"Morteza Naghavi MD , Nathan D. Wong PhD , Michael V. McConnell MD, MSEE , David J. Maron MD , Khurram Nasir MD , Claudia I. Henschke MD, PhD , David F. Yankelevitz MD , Zahi A. Fayad PhD , Rozemarijn Vliegenthart MD, PhD , Kim A. Williams Sr. MD , Roxana Mehran MD , Mathew Budoff MD , Daniel Berman MD , Jamal S. Rana MD, PhD , Prediman K. Shah MD , Robert A. Kloner MD, PhD , Jagat Narula MD, PhD , Philip Greenland MD , Valentin Fuster MD, PhD","doi":"10.1016/j.jcmg.2025.10.020","DOIUrl":"10.1016/j.jcmg.2025.10.020","url":null,"abstract":"<div><div>Atherosclerotic cardiovascular disease (ASCVD), in particular atherosclerotic coronary artery disease (CAD), is the leading cause of death in the United States and globally. In the majority of ASCVD victims, the first sign is an acute event (heart attack or stroke) with a high fatality rate. It is widely accepted that most CAD deaths are preventable if asymptomatic at-risk patients are diagnosed and treated before the onset of clinical symptoms. In the past 30 years, numerous studies conclusively demonstrated that coronary artery calcium (CAC) imaging diagnoses patients with subclinical CAD and predicts adverse outcomes beyond conventional risk factors such as hyperlipidemia, hypertension, smoking, and diabetes. Current ASCVD prevention guidelines issued by U.S. cardiovascular professional societies recommend risk factor assessment to screen individuals who may be at risk, followed by CAC imaging in the borderline- and intermediate-risk categories to diagnose and quantify the severity of CAD to guide treatment. However, most payers do not follow these guidelines to cover CAC imaging requiring patients to pay out of pocket, resulting in underdiagnosis and failure to prevent costly cardiovascular events. In this statement, we elaborate on the diagnostic use of CAC imaging and call on health care providers, payers, and policymakers to follow the ASCVD prevention guidelines and provide coverage. Covering the appropriate diagnostic use of CAC will enable physicians to perform shared decision-making for the treatment of patients with asymptomatic CAD and personalize the intensity of the treatment based on the extent of CAD. Specifically, this statement focuses on the diagnostic role of CAC imaging rather than its potential as a universal screening test. Although there are rationales for population-wide screening, such an approach would require large-scale outcome studies and is beyond the scope of this paper.</div></div>","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 266-273"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145717981","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.jcmg.2025.08.016
Rafail A. Kotronias MBChB, MS , Leonardo Portolan MD , Cheng Xie MBChB, DPhil, Vanessa M. Ferreira MD, Dphil, Betty Raman MD, Dphil, Ernst Klotz Dipl Phys, Giovanni L. De Maria MD, PhD, Ron Blankstein MD, Keith M. Channon MBChB, MD, Stefan Neubauer MD, Charalambos Antoniades MD, PhD
{"title":"Evaluating Acute Ischemic Myocardial Injury With Photon-Counting Computed Tomography","authors":"Rafail A. Kotronias MBChB, MS , Leonardo Portolan MD , Cheng Xie MBChB, DPhil, Vanessa M. Ferreira MD, Dphil, Betty Raman MD, Dphil, Ernst Klotz Dipl Phys, Giovanni L. De Maria MD, PhD, Ron Blankstein MD, Keith M. Channon MBChB, MD, Stefan Neubauer MD, Charalambos Antoniades MD, PhD","doi":"10.1016/j.jcmg.2025.08.016","DOIUrl":"10.1016/j.jcmg.2025.08.016","url":null,"abstract":"","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 284-287"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145194456","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.jcmg.2025.08.014
Osnat Itzhaki Ben Zadok MD, MS, Stephen J. Hankinson MD, Ashraf Hamdan MD, Sylvain L. Carre MS, Yee-Ping Sun MD, Rhanderson N. Cardoso MD, MHS, Tzlil Grinberg MD, Pinak B. Shah MD, Anju Nohria MD, MS, Sanjay Divakaran MD, MPH
{"title":"The Predictive Accuracy of Aortic Valve Calcium Score in Mediastinal Radiation Therapy Survivors","authors":"Osnat Itzhaki Ben Zadok MD, MS, Stephen J. Hankinson MD, Ashraf Hamdan MD, Sylvain L. Carre MS, Yee-Ping Sun MD, Rhanderson N. Cardoso MD, MHS, Tzlil Grinberg MD, Pinak B. Shah MD, Anju Nohria MD, MS, Sanjay Divakaran MD, MPH","doi":"10.1016/j.jcmg.2025.08.014","DOIUrl":"10.1016/j.jcmg.2025.08.014","url":null,"abstract":"","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 282-283"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145134074","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.jcmg.2025.09.022
Maan Malahfji MD , Mujtaba Saeed MD , Duc T. Nguyen MD, PhD , Yodying Kaolawanich MD , Hossam Lababidi MD , El-Moatasem Gabr MD , Alan Pan MS , Valentina Crudo MD , Michael J. Reardon MD , Michael Elliott MD , João L. Cavalcante MD , Venkateshwar Polsani MD , Sherif F. Nagueh MD , Robert O. Bonow MD , William A. Zoghbi MD , Raymond J. Kim MD , Dipan J. Shah MD
<div><h3>Background</h3><div>Management of patients with combined aortic and mitral regurgitation (AR and MR) is largely based on expert opinion. Specifically, the outcomes of patients with combined moderate AR and moderate MR under medical surveillance are uncertain.</div></div><div><h3>Objectives</h3><div>This study aimed to evaluate cardiac remodeling using cardiac magnetic resonance (CMR) in patients with combined AR/MR compared with isolated AR, to assess degree of MR associated with adverse outcomes, and evaluate the outcomes of asymptomatic patients with combined moderate AR and moderate MR under medical surveillance.</div></div><div><h3>Methods</h3><div>The authors conducted a multicenter observational outcome study of patients with moderate or severe AR on CMR, and evaluated the etiology and degree of concomitant MR in patients with combined AR and MR. They excluded patients if they had prior valvular surgery, > mild valve stenosis, hypertrophic or infiltrative cardiomyopathy, or congenital heart disease except bicuspid aortic valve. The authors evaluated ventricular volumes and function across the spectrum of regurgitation severity. Receiver-operating characteristic analyses for the association of concomitant MR severity with outcomes were performed. The primary outcome was all-cause death. Secondary outcome was all-cause death or heart failure (HF) hospitalization. Patients were censored at the time of valvular surgery or intervention. Propensity score matching was done between isolated AR and the combined AR/MR groups.</div></div><div><h3>Results</h3><div>The authors studied 915 patients with a median age of 61 years (Q1-Q3: 49-72 years), 79.5% male, 29% with bicuspid aortic valve, and a median AR fraction of 38% (Q1-Q3: 32%-45%). In 251 of 915 patients (27.4%) with concomitant MR, the median MR fraction was 24% (Q1-Q3: 17%-35%). The presence of concomitant ≥moderate MR (14.2% of the total population) was associated with a greater increase in ventricular volumes per unit increase in AR severity, and a decline in ventricular function (<em>P</em> for interaction ≤0.01). During a median follow-up of 3.0 years (Q1-Q3: 1.1-5.6 years), there were 152 deaths. Presence of concomitant ≥moderate MR was associated with an increased hazard for all-cause death (HR: 2.77; 95% CI: 1.91-4.01; <em>P <</em> 0.001), and the secondary outcome of death or HF (HR: 2.62; 95% CI: 1.87-3.67; <em>P <</em> 0.001). In asymptomatic or minimally symptomatic patients undergoing medical surveillance, the presence of combined moderate AR and moderate MR was independently associated with a higher hazard for the primary and secondary outcomes compared with isolated AR, independent of age, sex, comorbidities, ejection fraction, and end-systolic volume. Findings were consistent in the propensity matched cohort.</div></div><div><h3>Conclusions</h3><div>The presence of combined AR and MR on CMR is associated with a greater extent of ventricular remodeling and incr
{"title":"Cardiac Remodeling and Outcomes of Patients With Combined Aortic and Mitral Regurgitation","authors":"Maan Malahfji MD , Mujtaba Saeed MD , Duc T. Nguyen MD, PhD , Yodying Kaolawanich MD , Hossam Lababidi MD , El-Moatasem Gabr MD , Alan Pan MS , Valentina Crudo MD , Michael J. Reardon MD , Michael Elliott MD , João L. Cavalcante MD , Venkateshwar Polsani MD , Sherif F. Nagueh MD , Robert O. Bonow MD , William A. Zoghbi MD , Raymond J. Kim MD , Dipan J. Shah MD","doi":"10.1016/j.jcmg.2025.09.022","DOIUrl":"10.1016/j.jcmg.2025.09.022","url":null,"abstract":"<div><h3>Background</h3><div>Management of patients with combined aortic and mitral regurgitation (AR and MR) is largely based on expert opinion. Specifically, the outcomes of patients with combined moderate AR and moderate MR under medical surveillance are uncertain.</div></div><div><h3>Objectives</h3><div>This study aimed to evaluate cardiac remodeling using cardiac magnetic resonance (CMR) in patients with combined AR/MR compared with isolated AR, to assess degree of MR associated with adverse outcomes, and evaluate the outcomes of asymptomatic patients with combined moderate AR and moderate MR under medical surveillance.</div></div><div><h3>Methods</h3><div>The authors conducted a multicenter observational outcome study of patients with moderate or severe AR on CMR, and evaluated the etiology and degree of concomitant MR in patients with combined AR and MR. They excluded patients if they had prior valvular surgery, > mild valve stenosis, hypertrophic or infiltrative cardiomyopathy, or congenital heart disease except bicuspid aortic valve. The authors evaluated ventricular volumes and function across the spectrum of regurgitation severity. Receiver-operating characteristic analyses for the association of concomitant MR severity with outcomes were performed. The primary outcome was all-cause death. Secondary outcome was all-cause death or heart failure (HF) hospitalization. Patients were censored at the time of valvular surgery or intervention. Propensity score matching was done between isolated AR and the combined AR/MR groups.</div></div><div><h3>Results</h3><div>The authors studied 915 patients with a median age of 61 years (Q1-Q3: 49-72 years), 79.5% male, 29% with bicuspid aortic valve, and a median AR fraction of 38% (Q1-Q3: 32%-45%). In 251 of 915 patients (27.4%) with concomitant MR, the median MR fraction was 24% (Q1-Q3: 17%-35%). The presence of concomitant ≥moderate MR (14.2% of the total population) was associated with a greater increase in ventricular volumes per unit increase in AR severity, and a decline in ventricular function (<em>P</em> for interaction ≤0.01). During a median follow-up of 3.0 years (Q1-Q3: 1.1-5.6 years), there were 152 deaths. Presence of concomitant ≥moderate MR was associated with an increased hazard for all-cause death (HR: 2.77; 95% CI: 1.91-4.01; <em>P <</em> 0.001), and the secondary outcome of death or HF (HR: 2.62; 95% CI: 1.87-3.67; <em>P <</em> 0.001). In asymptomatic or minimally symptomatic patients undergoing medical surveillance, the presence of combined moderate AR and moderate MR was independently associated with a higher hazard for the primary and secondary outcomes compared with isolated AR, independent of age, sex, comorbidities, ejection fraction, and end-systolic volume. Findings were consistent in the propensity matched cohort.</div></div><div><h3>Conclusions</h3><div>The presence of combined AR and MR on CMR is associated with a greater extent of ventricular remodeling and incr","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 180-193"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145411491","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-02-01DOI: 10.1016/j.jcmg.2025.09.013
Jolien Geers MD , Neil Craig MD , Kajetan Grodecki MD, PhD , Maria Lembo MD, PhD , Shruti S. Joshi MD, PhD , Trisha Singh MD, PhD , Rong Bing MD, PhD , Jacek Kwieciński MD, PhD , Lorenzo Carnevale PhD , Dorien Kimenai PhD , Soongu Kwak MD, PhD , Seung-Pyo Lee MD, PhD , Kush Patel MD , Thomas Treibel MD, PhD , Aroa Ruiz Muñoz MS , Jose F. Rodriguez Palomares MD, PhD , Jae-Kwan Song MD, PhD , Marie-Annick Clavel DVM, PhD , Pamela Piña MD , Daniel Lorenzatti MD , Marc R. Dweck MD, PhD
Background
Calcium scoring from noncontrast computed tomography (CT) is used clinically to adjudicate aortic stenosis severity in patients with discordant echocardiography.
Objectives
The aim of this study was to investigate whether quantification of aortic valve calcium volume from computed tomography angiography (CTA) can provide robust diagnostic discrimination of disease severity and inform risk stratification of patients with aortic stenosis.
Methods
Patients with mild to severe aortic stenosis who underwent concurrent CTA and echocardiography were included in a retrospective international multicenter observational cohort study. Accuracy of aortic valve calcium volume to diagnose severe aortic stenosis in patients with concordant disease on echocardiography was assessed. Association of aortic valve calcium volume with the incidence of aortic valve replacement or all-cause death was investigated.
Results
The study included 1,521 patients (mean age: 74 ± 10 years; 44% female; median peak aortic jet velocity: 3.8 m/s [Q1-Q3: 3.1-4.5 m/s]). Indexed aortic valve calcium volume correlated with peak aortic jet velocity (ρ = 0.723; P < 0.001) and noncontrast CT calcium score (ρ = 0.896; P < 0.001). In the derivation cohort (n = 689), sex-specific thresholds for indexed calcium volume (men: 122 mm3/cm2; women: 61 mm3/cm2) provided excellent diagnostic discrimination for severe aortic stenosis (C-statistic: 0.900 for men; 0.926 for women). Similar diagnostic discrimination was observed in the validation cohort (n = 459; C-statistic: 0.933 for men; 0.944 for women). Clinical outcomes were available in 711 patients (25% with discordant echocardiography), with 249 reaching the primary endpoint after 26 months (Q1-Q3: 12-53 months). Indexed calcium volume thresholds were independently associated with aortic valve replacement or all-cause mortality in both the cohort as a whole (HR: 2.01 [95% CI: 1.30-3.10]; P < 0.01) and those with discordant echocardiography (HR: 1.58 [95% CI: 1.01-2.44]).
Conclusions
In patients with aortic stenosis, indexed aortic valve calcium volume from CTA provides accurate discrimination of disease severity and additive prognostic information. This technique can be easily applied to patients undergoing CTA for transcatheter aortic valve replacement or coronary artery evaluation without the need for a separate noncontrast CT scan.
背景：非对比计算机断层扫描（CT）的钙评分在临床上用于判断超声心动图不一致患者主动脉狭窄的严重程度。目的：本研究的目的是探讨计算机断层血管造影（CTA）对主动脉瓣钙容量的量化是否能提供对疾病严重程度的有力诊断，并为主动脉瓣狭窄患者的风险分层提供信息。方法一项回顾性国际多中心观察队列研究纳入了同时进行CTA和超声心动图检查的轻度至重度主动脉瓣狭窄患者。评价超声心动图上主动脉瓣钙容量诊断重度主动脉狭窄的准确性。研究了主动脉瓣钙容量与主动脉瓣置换术或全因死亡发生率的关系。结果共纳入1521例患者，平均年龄74±10岁，女性44%，主动脉喷射速度中位数峰值为3.8 m/s [Q1-Q3: 3.1-4.5 m/s]。主动脉瓣指数化钙容量与峰值主动脉射流速度（ρ = 0.723, P < 0.001）和CT造影钙评分（ρ = 0.896, P < 0.001）相关。在衍生队列（n = 689）中，指数钙容量的性别特异性阈值（男性：122 mm3/cm2；女性：61 mm3/cm2）提供了对严重主动脉狭窄的良好诊断鉴别（c统计量：男性0.900；女性0.926）。在验证队列中观察到类似的诊断歧视（n = 459； c统计量：男性0.933；女性0.944）。711例患者的临床结果（25%超声心动图不一致），249例在26个月后达到主要终点（Q1-Q3: 12-53个月）。在整个队列中，指数钙容量阈值与主动脉瓣置换术或全因死亡率独立相关（HR: 2.01 [95% CI: 1.30-3.10]; P < 0.01），超声心动图不一致者（HR: 1.58 [95% CI: 1.01-2.44]）。结论在主动脉瓣狭窄患者中，CTA指数主动脉瓣钙容量可准确区分病情严重程度和附加预后信息。这项技术可以很容易地应用于接受CTA的经导管主动脉瓣置换术或冠状动脉评估的患者，而无需单独进行非对比CT扫描。
{"title":"Indexed Aortic Valve Calcium Volume by Computed Tomography Angiography in Patients With Aortic Stenosis","authors":"Jolien Geers MD , Neil Craig MD , Kajetan Grodecki MD, PhD , Maria Lembo MD, PhD , Shruti S. Joshi MD, PhD , Trisha Singh MD, PhD , Rong Bing MD, PhD , Jacek Kwieciński MD, PhD , Lorenzo Carnevale PhD , Dorien Kimenai PhD , Soongu Kwak MD, PhD , Seung-Pyo Lee MD, PhD , Kush Patel MD , Thomas Treibel MD, PhD , Aroa Ruiz Muñoz MS , Jose F. Rodriguez Palomares MD, PhD , Jae-Kwan Song MD, PhD , Marie-Annick Clavel DVM, PhD , Pamela Piña MD , Daniel Lorenzatti MD , Marc R. Dweck MD, PhD","doi":"10.1016/j.jcmg.2025.09.013","DOIUrl":"10.1016/j.jcmg.2025.09.013","url":null,"abstract":"<div><h3>Background</h3><div>Calcium scoring from noncontrast computed tomography (CT) is used clinically to adjudicate aortic stenosis severity in patients with discordant echocardiography.</div></div><div><h3>Objectives</h3><div>The aim of this study was to investigate whether quantification of aortic valve calcium volume from computed tomography angiography (CTA) can provide robust diagnostic discrimination of disease severity and inform risk stratification of patients with aortic stenosis.</div></div><div><h3>Methods</h3><div>Patients with mild to severe aortic stenosis who underwent concurrent CTA and echocardiography were included in a retrospective international multicenter observational cohort study. Accuracy of aortic valve calcium volume to diagnose severe aortic stenosis in patients with concordant disease on echocardiography was assessed. Association of aortic valve calcium volume with the incidence of aortic valve replacement or all-cause death was investigated.</div></div><div><h3>Results</h3><div>The study included 1,521 patients (mean age: 74 ± 10 years; 44% female; median peak aortic jet velocity: 3.8 m/s [Q1-Q3: 3.1-4.5 m/s]). Indexed aortic valve calcium volume correlated with peak aortic jet velocity (ρ = 0.723; <em>P <</em> 0.001) and noncontrast CT calcium score (ρ = 0.896; <em>P <</em> 0.001). In the derivation cohort (n = 689), sex-specific thresholds for indexed calcium volume (men: 122 mm<sup>3</sup>/cm<sup>2</sup>; women: 61 mm<sup>3</sup>/cm<sup>2</sup>) provided excellent diagnostic discrimination for severe aortic stenosis (C-statistic: 0.900 for men; 0.926 for women). Similar diagnostic discrimination was observed in the validation cohort (n = 459; C-statistic: 0.933 for men; 0.944 for women). Clinical outcomes were available in 711 patients (25% with discordant echocardiography), with 249 reaching the primary endpoint after 26 months (Q1-Q3: 12-53 months). Indexed calcium volume thresholds were independently associated with aortic valve replacement or all-cause mortality in both the cohort as a whole (HR: 2.01 [95% CI: 1.30-3.10]; <em>P <</em> 0.01) and those with discordant echocardiography (HR: 1.58 [95% CI: 1.01-2.44]).</div></div><div><h3>Conclusions</h3><div>In patients with aortic stenosis, indexed aortic valve calcium volume from CTA provides accurate discrimination of disease severity and additive prognostic information. This technique can be easily applied to patients undergoing CTA for transcatheter aortic valve replacement or coronary artery evaluation without the need for a separate noncontrast CT scan.</div></div>","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 210-221"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145357618","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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