European heart journal. Imaging methods and practice最新文献

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.

Aims: Valvular heart disease is a leading cause of cardiovascular morbidity and mortality globally, with women experiencing delayed referrals, difficulties recognizing atypical symptoms, and suboptimal adherence to guideline-based therapies, resulting in worse outcomes. However, the literature identifying these disparities remains limited, underscoring the need for a comprehensive registry to address these gaps. The Valvular Heart Disease in Women Registry (VHD-W) aims to provide real-world insights into gender differences by examining treatment patterns, guideline adherence, and clinical results.

Methods and results: The VHD-W is an international, multicenter, non-commercial, investigator-initiated, multipurpose registry endorsed by the European Association of Cardiovascular Imaging. The VHD-W involves adult patients with moderate-to-severe valvular heart disease admitted, either urgently or electively, to the cardiology inpatient service. The study aims to enrol 800 patients, balanced between genders, across more than 70 centres worldwide, over a 6-month period from the registry inception in March 2024 until the end of December 2025. Data will be collected at inpatient admission, inpatient discharge, and 1-year follow-up, including demographics, medical history, physical examination, biomarkers, echocardiography, other imaging results, and management. Conclusion The VHD-W is the first registry to focus on gender disparities in valvular heart disease in a real-world setting, aiming to fill a significant management gap that will help develop gender-specific, evidence-based guidelines for valvular heart disease.

Aims: The hemodynamic consequences of aortic stenosis (AS) on supra-aortic trunks may play a potential role during the diagnosis of concomitant internal carotid artery (ICA) stenosis by dampening blood flow velocity. To investigate the effect of AS on ICA blood flow we evaluated carotid and vertebral blood flow velocity indexes in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods and results: Patients admitted for endovascular treatment of a severe AS underwent supra-aortic duplex ultrasound examination prior and after TAVI to be enrolled in the study. Patients with symptomatic or severe ICA stenosis were excluded. Patients with other cardiac impairments that could configure a confounding factor were excluded. One hundred and five patients of a median age of 80 years met the study inclusion criteria. The median peak systolic velocity (PSV) of the assessed supra-aortic arteries increased after TAVI: common carotid artery (CCA) from 64.5 to 78.0 cm/s (+24%; P < 0.01), ICA from 67.0 to 90.5 cm/s (+36%; P < 0.01), and vertebral artery (VA) from 44.0 to 51.0 cm/s (+17%; P < 0.01). Median end-diastolic velocity (EDV) also increased: CCA from 12.0 to 14.0 cm/s (+12%; P < 0.01), ICA from 19.0 to 23.0 cm/s (+20%; P < 0.01), and VA from 10.0 to 11.0 cm/s (+18%; P < 0.01). In parallel, median acceleration time (AT) decreased markedly at each site: CCA from 0.180 to 0.100 s (-44%; P < 0.01), ICA from 0.195 to 0.100 s (-41%; P < 0.01), and VA from 0.180 to 0.100 s (-36%; P < 0.01).

Conclusion: Severe AS significantly affects supra-aortic arteries blood flow as assessed by duplex, by decreasing both PSV and EDV and increasing AT. This study suggests that carotid ultrasound criteria to assess ICA stenosis severity should be re-evaluated in larger multi-centre studies to validate their predictive values in patients with concomitant AS.

Mitochondrial myopathies are heritable conditions caused by genetic variations in mitochondrial DNA or nuclear DNA. These result in dysfunctional cellular oxidative phosphorylation and ATP production, affecting organs with high-energy requirements such as the heart, brain and skeletal muscle. Cardiac involvement is common affecting one third of patients and includes left ventricular hypertrophy, conduction disease, Wolff-Parkinson-White syndrome, and dilated cardiomyopathy. Due to the variability in the clinical presentation, a multiparametric approach incorporating clinical, biochemical, histological/histochemical and genetic criteria is required to make the diagnosis. Cardiologists should be aware of the clinical red flags and imaging findings and how to differentiate mitochondrial cardiomyopathy from other causes of left ventricular hypertrophy. Cardiovascular magnetic resonance imaging is a highly sensitive tool for depicting myocardial abnormalities to aid in both the diagnosis of patients presenting with left ventricular hypertrophy, and in the assessment of cardiac involvement in patients with a known diagnosis of mitochondrial myopathy, as this is an independent predictor of morbidity and early mortality. The most common CMRI findings include increased maximal LV wall thickness and mass and non-ischaemic subepicardial and midwall LGE, most commonly affecting the basal inferolateral or lateral wall. Future studies should consider integrating late gadolinium enhancement imaging into risk prediction models to enhance stratification of major adverse cardiac events such as heart failure and arrhythmia. As our understanding of mitochondrial disease evolves, integrating advanced imaging with molecular diagnostics will be essential for early detection of disease, improved risk prediction and outcomes.

Aims: Functional mitral regurgitation is strongly associated with dilatation of the mitral annulus. We aimed to investigate how remodelling of the left ventricle and left atrium impacts the mitral annulus size and function in patients with transmural myocardial infarction.

Methods and results: In this prospective observational study, patients with ST-elevation myocardial infarction were examined with 3D echocardiography at admission and at 1-year follow-up (n = 87). Size and function of the left cardiac chambers and the mitral annulus was analysed. The cohort was divided into groups with (n = 16) or without (n = 71) mitral annular remodelling, defined as an area increase of 15% or more, from baseline to follow-up. During follow-up, the group without mitral annular remodelling had stable volumes and improved function for both the left ventricle and the left atrium. Although the group with mitral annular remodelling also exhibited improved left ventricular function, both left ventricular volume and left atrial volume increased, and no improvement was seen in left atrial emptying fraction or left atrial reservoir or contractile strain. In linear regression analysis, increased mitral annular area at follow-up was associated with change in both left atrial [β = 0.025 (0.007, 0.043), P = 0.006] and left ventricular volume [β = 0.014 (0.003, 0.025), P = 0.012].

Conclusion: Mitral annular remodelling after transmural myocardial infarction is associated with increased volumes of the left ventricle and the left atrium, and absence of atrial functional improvement. Both increasing left atrial and left ventricular volume are associated with mitral annular dilatation, but left atrial volume is the strongest factor.

Aims: Understanding changes in ATP metabolism may lead to improved risk stratification in severe primary mitral regurgitation (MR). Here, we seek to compare the energetic phenotype of volume-overload pathological hypertrophy with athletic hypertrophy and with the normal heart under catecholamine stress.

Methods and results: Nineteen severe-MR patients underwent cardiac magnetic resonance and ³¹P-spectroscopy for energetics, including phosphocreatine to adenosine triphosphate ratio (PCr/ATP), the pseudo-first-order forward rate constant of the creatine kinase reaction (k _f) and CK flux (k _f × [PCr]). When compared with 20 healthy controls, severe MR was associated with lower PCr/ATP (1.58 ± 0.32 vs. 2.08 ± 0.28, P < 0.001). This is related to the severity of regurgitation (r -0.59, P < 0.001) but not to LVEF (r -0.20, P = 0.23) or LV systolic strain (P = 0.18). When compared to 17 athletes with similarly increased end-diastolic volume (athletes 107 ± 10 mL/m² vs. 114 ± 22, P = 0.29), severe MR had greater total cardiac output (by 42%, P < 0.001), and lower PCr/ATP (by 28%, P < 0.001) and CK flux (by 41%, P = 0.04). When compared to normal hearts during dobutamine stress at matched cardiac output levels, median k _f (by 45%, P = 0.08) and CK flux (by 53%, P = 0.02) were lower in severe MR. PCr/ATP increased (by 17%, P = 0.04) following mitral valve repair (MVR) in a subset of patients (n = 14, median 7 months). Seven patients during MVR and six patients without volume loading donated LV biopsy, revealing that creatine was not lower in severe MR.

Conclusion: Even with normal LVEF, severe MR is associated with reduced PCr/ATP, CK k _f, and CK flux. PCr/ATP reduction resolved with MVR. Thus, targeting CK capacity and/or flux may be a therapeutic strategy to prevent/treat systolic failure in MR.

Aims: Fungal infective endocarditis (IE) is known to carry high morbidity and mortality, yet contemporary literature on the imaging features and prognosis of this patient population remains very limited.

Methods and results: In this retrospective cohort study, all patients admitted to the Cleveland Clinic between 2009 and 2021 with fungal IE were reviewed. Data were collected on clinical presentation, imaging findings, and patient outcomes. Univariate and multivariate regression analyses for risk factors associated with mortality and with post-surgical re-infection were conducted. A total of 82 patients were included. The mean age was 51 ± 16 years, 77% had prosthetic valves, 29% had aortic grafts, and the rate of intravenous drug use history was 39%. Echocardiographic features differed between organisms, with no Histoplasma patients demonstrating infectious annular involvement. The rate of patients with large vegetations (>1 cm) was 70%. In all, 43% had severe valvular dysfunction, 30% had paravalvular abscess, and 21% had aortic graft infections. Of the four patients undergoing nuclear studies, none of them had intracardiac uptake. Inpatient and 1-year mortality rates were 15% and 30%, respectively. Patients who received medical therapy without surgery had worse mortality than those who underwent surgery (P = 0.015).

Conclusion: We present the largest contemporary cohort study of fungal IE to date. Rates of complicated infection in fungal IE were high. Multimodality imaging with transesophageal echocardiography and computed tomography was critical in diagnosis. Although useful in identifying peripheral complications, nuclear studies may have lower sensitivity in identifying fungal IE, and further research is warranted in this population. While still elevated, 1-year mortality rates (30%) were significantly lower in our patient cohort than previously reported.

Aims: The presence of a left atrial appendage (LAA) thrombus is an absolute contraindication for ablation. Despite the use of oral anticoagulant (OAC) therapy, LAA thrombi may still occur. The objective of this study is to identify the incidence of LAA thrombi in transoesophageal echocardiography (TEE) (the gold standard) and computed tomography (CT) scans and to investigate any correlation in thrombus detection between the two methods. Additionally, the study aims to investigate whether LAA flow velocity or volume influences thrombus detection.

Methods and results: Between May 2018 and October 2023, patients with atrial fibrillation/atrial tachycardia (AF/AT) under OAC, which were scheduled for AF catheter ablation, were included. TEE and CT were carried out at intervals of up to 7 days. LAA flow velocity was measured in the TEE. The volume of the LA, including LAA, excluding the pulmonary veins (PV), was obtained from a 3D reconstruction of the LA from CT. The study included 283 patients (pts), mean age of 66y (± 9 years), 182 male, mean CHA₂DS₂-VA score 3 [0-7]. All pts were orally anticoagulated with the majority under non-vitamin K antagonist oral anticoagulant (NOAC) (n = 265). Mean LA volume (LA + LAA) was 158 mL (± 45 mL). LAA flow velocity was reduced (<40 cm/s) in 119 pts (42%). In the majority of cases TEE and CT were performed at the same day (51%) or with an interval of 1 day (22%). A LAA thrombus was identified in 35 (12%) patients at least in one of the two methods. CT detected a thrombus in 27 patients, while TEE identified a thrombus in 16 patients, with both methods agreeing in 8 cases. A significant association between LAA flow velocity and thrombus detection by TEE was observed (P < 0.001; r = 0.36). In contrast, no significant relationship was observed between left atrial volume and thrombus presence on CT (P = 0.964).

Conclusion: In 12% of OAC-treated patients, a thrombus was detected in at least one exam, with concordant TEE and CT diagnoses in only 25%. Both methods excluded thrombi in 80% of cases. LAA flow velocity correlated with TEE findings, whereas LA volume showed no association with CT. Discrepancies highlight diagnostic challenges: TEE is operator-dependent, and CT is limited by flow and timing.