European heart journal. Imaging methods and practice最新文献

Background: Reference ranges for myocardial work indices are limited by the scarcity of data from the clinically relevant group of elderly individuals. Myocardial work indices constitute load-adjusted left ventricular function, and main components include global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE).

Aims: To establish reference values for myocardial work indices and pressure-strain loop shape from guideline-directed recordings in a healthy population spanning a broad age range.

Methods and results: We assessed myocardial work in healthy participants from the HUNT4Echo study. Global longitudinal strain was obtained by two expert cardiologists using two-dimensional speckle tracking, and systolic blood pressure from brachial measurements. Timing of valve events was performed by a single observer supervised by the expert cardiologists. Among 1239 participants (mean age 57, 55% female), reference ranges for myocardial work indices were as follows: GWI 1367-2583 mmHg%, GCW 1664-2972 mmHg%, GWW 38-328 mmHg%, and GWE 88-98%. Age was associated with lower GWI and GWE, and higher GCW and GWW (all P < 0.05). Sex influenced myocardial work indices, with somewhat higher GWI and GCW in females (P ≤ 0.001). The shape of the pressure-strain loops was narrower in older groups, while GWI (the area encompassed by the loop) remained constant across age groups.

Conclusion: Myocardial work indices were influenced by age and sex, but effects were minor and have limited clinical relevance. Despite preserved GWI by higher age, the pressure-strain loop shape changes significantly - underscoring the importance of integrating strain and afterload when assessing left ventricular function.

Trial registration number: Not applicable.

Introduction: Grading of aortic stenosis (AS) is paramount to determine the ideal timing for aortic valve replacement. However, echocardiographic assessment of AS is challenging and subject to inaccuracy. Increased turbulent kinetic energy (TKE) in the aorta, created by a restricted opening stenotic aortic valve, could serve as a new marker for assessing AS severity. However, in this contest, TKE evaluated with ultrasound colour Doppler have not yet been clinically validated.

Methods and results: Porcine aortic valves were tested ex-vivo in a left heart mock loop under various flowrates (1, 2.5, and 4 L/min) and three stiffness grades (SGa, SGb, SGc as native, stiffer, and stiffest stiffness grade, respectively). Reference TKE values were obtained using backlight particle tracking velocimetry. In parallel, TKE was estimated from ultrasound colour Doppler measurements by computing the local spatial fluctuations of blood flow velocities. Transvalvular pressure gradients were evaluated both with continuous wave Doppler and pressure sensors (PGaolv). At 4 L/min, pressure gradients with continuous wave Doppler for SGc reached severe AS levels (41 mmHg ± 14). Both TKE measurement methods, adjusted for flow rates, increased significantly across all stiffness grades and distinguished between severe (SGc) and non-severe (SGa and SGb) AS.

Conclusion: In this ex-vivo AS model, both TKE measurement methods successfully differentiated severe from non-severe AS. These findings underscore the potential importance of ultrasound colour Doppler echocardiography in estimating energy loss through turbulence, paving the way for the development of a new diagnostic tool for grading AS severity.

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.

Aims: Bicuspid aortic valve (BAV) stenosis complicates transcatheter aortic valve replacement (TAVR) planning, with no validated automated measurement algorithm available. We developed Cardioverse, the first fully automated deep learning algorithm for BAV anatomical assessment in TAVR planning.

Methods and results: We conducted a large-scale, multicenter retrospective study encompassing 1,147 consecutive patients with BAV undergoing TAVR across 16 high-volume Chinese centers (March 2019-February 2023). Cardioverse was trained on this cohort and evaluated in an internal (n = 437) and external (n = 110) validation cohorts. Our novel Cardioverse algorithm demonstrated exceptional segmentation performance across all anatomical targets with Dice similarity coefficients >0.97 for coronary cusps and ostia. Critically, the algorithm achieved unprecedented workflow efficiency gains: 80% reduction in assessment time [241.0 IQR (181.0, 297.0) vs. 1251.0 IQR (872.0, 1408.0) seconds], 85% reduction in user interactions [57.0 IQR (45.0, 78.0) vs. 382.5 IQR (285.5, 475.0) clicks], and 87% reduction in manual effort [7.5 IQR (4.8, 9.3) vs. 57.2 IQR (43.5, 68.4) meters mouse movement] compared to expert observers (P < 0.001). Importantly, accuracy was maintained across all BAV phenotypes with correlation coefficients >0.91 for all critical measurements, including annular dimensions, calcification quantification, and aortic root morphology assessment.

Conclusion: Cardioverse transforms pre-TAVR assessment for BAV patients, offering a validated solution combining accuracy and efficiency. It reduces assessment time from over 20 min to < 5 min, addressing the need for standardized, rapid, and reliable BAV evaluation. Its robust performance across diverse BAV phenotypes makes it a crucial tool for enhancing TAVR planning consistency.

Clinical trial registration: ClinicalTrials.gov Protocol Registration System (NCT05044338).

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.