European heart journal. Imaging methods and practice最新文献

Positron emission tomography (PET) is the most advanced myocardial perfusion (MPI) technique for the non-invasive assessment of coronary artery disease and its many manifestations, including ischaemia, hibernation, and scar. This comprehensive overview aims to empower clinicians, technicians, and patients with clear, structured knowledge on performing and interpreting PET MPI. This document will describe stress protocols, patient preparation, tracer pharmacodynamics and nuclear properties, camera capabilities, post-acquisition processing, and a comprehensive and clear reporting system for both perfusion and viability imaging.

Introduction: Myocardial perfusion imaging (MPI) is used to evaluate ischaemia in patients with chronic total occlusion (CTO), but its prognostic implications following percutaneous coronary intervention (PCI) of CTO remain uncertain.

Purpose: To evaluate outcomes in patients treated with CTO-PCI stratified by moderate-severe ischaemia on MPI prior to intervention.

Methods and results: Patients from the Western Danish Heart Registry assessed by nuclear MPI and subsequently treated with CTO-PCI ≤ 6 months were included. Moderate-severe ischaemia was defined as ≥10% left ventricle involvement. Primary endpoints were all-cause mortality and a composite of major adverse cardio- and cerebrovascular events [MACCE; cardiovascular death, myocardial infarction (MI), stroke, and hospitalization for heart failure (HF) or angina pectoris]. Secondary endpoints included the individual MACCE components. Outcomes were compared between patients with and without moderate-severe ischaemia using multivariable Cox regression and competing risk regression at 90-day and 5-year follow-ups. Among 319 patients, 208 (65.2%) had moderate-severe ischaemia. All-cause mortality was similar between patients with and without moderate-severe ischaemia [adjusted hazard ratio (aHR) 1.12, 95% confidence interval (CI): 0.52-2.43], P = 0.77). The estimated risk of MACCE was comparable between groups at 90 days [aHR 0.76 (0.38-1.55), P = 0.46] and 5 years [aHR 0.74 (0.45-1.20), P = 0.22]. No difference was found in MI [5 years: aHR 0.76 (0.26-2.22), P = 0.61] or hospitalization for HF [90 days: aHR 0.44 (0.16-1.21), P = 0.11]; 5 years: aHR 0.62 (0.30-1.30), P = 0.21]. Hospitalization for angina was similar at 90 days [aHR 0.75 (0.26-2.16), P = 0.60], but a decreased 5-year risk was observed in patients with moderate-severe ischaemia [aHR 0.46 (0.23-0.91), P = 0.026].

Conclusion: Moderate-severe ischaemia on nuclear MPI was not associated with differences in mortality or MACCE after CTO-PCI but was associated with a lower long-term risk of angina hospitalization.

Point-of-care ultrasound (POCUS) has rapidly evolved from a diagnostic adjunct into an essential extension of bedside clinical reasoning in acute cardiovascular care. By providing immediate, physiologically grounded, and non-invasive information, POCUS enhances diagnostic accuracy, risk stratification, and therapeutic guidance in real time. Among its core applications, lung ultrasound enables reliable detection and monitoring of pulmonary congestion, outperforming traditional methods such as chest X-ray and physical examination. The Venous Excess Ultrasound Score offers a structured assessment of systemic venous congestion through abdominal venous Doppler patterns. The left ventricular outflow tract velocity-time integral serves as a reproducible surrogate of forward flow and cardiac output, while focused cardiac ultrasound provides rapid structural and functional evaluation of the heart. The reliability and prognostic value of these modalities have been supported by growing evidence across diverse clinical contexts, though standardization of training and acquisition protocols remains crucial for widespread implementation. Integration of POCUS into daily workflows-through structured, serial assessments of pulmonary, venous, and haemodynamic status-holds promise to refine decision-making, individualize treatment strategies, and improve outcomes. This review summarizes current evidence, methodological considerations, and practical implications of POCUS in acute cardiovascular medicine, emphasizing its complementarity to, rather than replacement of, traditional diagnostic tools.

Background: Echocardiographic measurements of the left ventricle (LV) are fundamental in diagnosing and monitoring cardiac disease. Still, current understanding of how heart rate influences these measurements is incomplete. We aimed to explore the relationship between heart rate and LV global longitudinal strain (GLS), ejection fraction (LVEF), end-diastolic (LVEDV), and end-systolic volumes (LVESV), using atrial pacing and a transparent multi-step deep learning (DL)-based method for fully automated measurements.

Methods and results: Fifty participants with permanent pacemakers were enrolled. Heart rate was increased by atrial pacing in increments of 10 beats/min, from 50 to 140 beats/min, with echocardiographic 10-beat cine-loops recorded at each step. A DL-based method was utilized to measure GLS, LVEF, LVEDV, and LVESV at all levels.A total of 10 161 heart cycles were analysed, with 97% feasibility. As heart rate increased, all LV measures displayed significant and near-linear reductions. From 60 to 140 beats/min, GLS decreased by 32% (95% CI: 19-44%), LVEF by 33% (95% CI: 19-47%), LVEDV by 31% (95% CI: 19-43%), and LVESV by 10% (95% CI: -5% to 24%). Processing time per cardiac cycle was 1.3 (0.4) s, corresponding to 3.7 h for the entire dataset.

Conclusion: Heart rate significantly influences echocardiographic measures of LV function and volume, emphasizing the necessity of incorporating heart rate into clinical interpretation and reporting of echocardiographic measurements. This study further demonstrates the potential of DL to advance cardiovascular research by enabling rapid, accurate, and reproducible analyses, previously unachievable due to the inherent constraints of manual measurements.

Cardiac resynchronization therapy (CRT) improves outcomes in patients with heart failure and broad QRS complex, yet 20-45% do not respond. Mechanical dyssynchrony (MechDys)-identified visually by septal flash and/or apical rocking (SFoAR)-is strongly associated with CRT benefit. This 'How to' paper outlines a practical four-step workflow for the visual assessment of MechDys. First, a high-quality, multi-view echocardiographic acquisition is essential. Second, septal flash4 (SF) is recognized as an early leftward septal motion, often with rebound, preceding lateral wall contraction; its magnitude depends on conduction delay, myocardial contractility, and right heart loading. Third, ApR is identified as a biphasic apical motion reflecting sequential septal and lateral wall contractions; its appearance may be modified by scarring, pacing, or imaging artefacts. MechDys is confirmed when either motion pattern is present. Clinically, the visual assessment of MechDys may improve patient selection for CRT, thus improving response rates. The ongoing AMEND-CRT trial is evaluating whether incorporating SFoAR assessment is non-inferior to guideline recommendations. Pending prospective evidence, existing observational data supports the use of visual assessment of MechDys to guide decision-making in patients with intermediate CRT indications.

Aims: Assessment of right ventricular volume is crucial for monitoring patients with congenital heart defects. However, due to the right ventricle's complex geometry, 2D echocardiography is challenging and MRI is commonly used to evaluate right ventricular volume. However, MRI has several limitations: it lacks bedside imaging, is time-consuming, and often requires sedation in patients with congenital heart defects. Therefore, we aimed to develop a reliable and simple method for calculating right ventricular volume using 2D echocardiography.

Methods and results: Standard apical 4-chamber and parasternal short-axis views were obtained using 2D echocardiography in 40 congenital heart defects patients. Right ventricular volumes were calculated using an ellipsoidal shell model, a truncated cone model and a novel approach based on a cone model: $V_{\mathrm{RV}}=\frac{2}{3}\frac{\left(A_{\mathrm{SAX}}+\frac{1}{8}\pi d_{\mathrm{TV}}^2\right)A_{4\mathrm{CH}}}{d_{\mathrm{TV}}}$ . The results were compared with right ventricular volumes obtained via MRI. The proposed cone-based model demonstrated excellent correlation to right ventricular volumes obtained by MRI (systolic: ICC = 0.98 (95% CI 0.95-0.99)/diastolic: ICC = 0.96 (95% CI 0.92-0.98)). The mean difference from MRI-measured systolic volume was 0.1 mL (SD ± 13.3) and from diastolic volume 5.2 mL (SD ± 28.2). Based on the root mean square error (RMSE) our cone model (RMSE 13.2 mL/28.4 mL systolic/diastolic) demonstrates significantly better predictive accuracy than the traditional ellipsoidal shell model (RMSE 20.8 mL/52.6 mL systolic/diastolic) and the truncated cone model (RMSE 25.1 mL/42.3 mL systolic/diastolic).

Conclusion: Our method shows excellent alignment with MRI data. It offers an accurate and rapid method for bedside assessment of right ventricular volume with 2D echocardiography, enhancing prompt and precise clinical decision-making.

Aims: The relationship between the extent and composition of coronary atherosclerosis and the severity of myocardial ischaemia remains incompletely understood. We assessed whether artificial intelligence-guided coronary computed tomography angiography-derived plaque burden and composition correlate with ischaemia severity.

Methods and results: We included 837 symptomatic patients undergoing coronary computed tomography angiography and subsequent ¹⁵O-water positron emission tomography myocardial perfusion imaging. Artificial intelligence-guided coronary computed tomography angiography was used to quantify plaque features-diameter stenosis, percent atheroma volume (PAV), percent non-calcified plaque volume (NCPV), and percent calcified plaque volume (CPV)-per patient and per major coronary artery (LAD, LCx, RCA). Ischaemia severity was classified into four categories based on regional hyperaemic myocardial blood flow. Increasing severity of ischaemia was associated with higher diameter stenosis and plaque burden (PAV, NCPV, CPV) on patient level and in all major coronary territories (overall P < 0.001). The LAD consistently demonstrated higher atherosclerotic burden as compared to the LCx and RCA. Ordinal logistic regression confirmed that diameter stenosis (OR 1.02-1.03, P < 0.001) and NCPV (OR 1.04-1.05, P = 0.011-0.031) were significant predictors of ischaemia severity in all coronary arteries, while CPV was predictive only in the LAD and RCA (OR 1.03-1.04, P = 0.002-0.015).

Conclusion: Artificial intelligence-guided coronary computed tomography angiography-derived measures of plaque burden and stenosis are associated with the severity of myocardial ischaemia, although overlapping distributions across ischaemia severity indicate that anatomical imaging alone may be insufficient for accurate phenotyping of flow-limiting CAD. These findings encourage for the integration of functional imaging with quantitative plaque analysis for a more comprehensive evaluation of coronary artery disease.

Right heart dysfunction increases morbidity and mortality in cardiovascular diseases. Four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) imaging evaluates detailed right heart physiology, including vorticity, flow dynamics, kinetic energy (KE) and energy loss (EL). This systematic review synthesized literature using 4D flow CMR to assess right atrial (RA) and right ventricular (RV) hemodynamics in health and disease. A systematic search of the Scopus database (up to March 2025) identified observational studies investigating 4D flow CMR of right heart function in adults. Data on RA flow dynamics, RV flow components, KE, EL, and hemodynamic parameters were narratively synthesized. Quality assessment used the AXIS tool From 240 identified articles, 17 studies (894 participants) met eligibility criteria, including healthy individuals and patients with pulmonary hypertension (PH). RA flow dynamics, described in five studies, were characterized by a dominant vortex in health, interrupted with disease. RV flow components consistently showed a decline in direct flow and increased residual volume with disease. Atrial and ventricular KE assessments revealed age, sex, and disease-specific alterations, with rotational flow appearing to conserve right atrial KE. Increased EL was noted in PH. 4D flow CMR is a powerful tool for assessing novel right heart hemodynamic parameters. Quantifying flow patterns, components, and energetics provides a comprehensive overview of right heart function, promising to improve the diagnosis, management, and prognostic stratification of right heart diseases.

Combined functional mitral and tricuspid regurgitation (FMR and FTR) is now recognized not just as the coexistence of two valvular lesions, but as a distinctive clinical syndrome signalling advanced biventricular dysfunction. These lesions, although secondary to myocardial and atrial remodelling, exert a significant haemodynamic burden and perpetuate a vicious cycle of chamber dilatation, pulmonary hypertension, and symptom persistence. Medical therapy remains foundational, but many patients require sequential or combined transcatheter interventions. Optimal management requires an integrated diagnostic strategy, informed by imaging, to guide the timing and targeting of interventions for each valve.