European heart journal. Imaging methods and practice最新文献

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.

Aims: The Heart Team (HT) concept is underscored in multiple guidelines, but the practical application is still challenging.

Objective: This survey, endorsed by the European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee and conducted by the EACVI Leaders of Tomorrow, aimed to explore the structure and dynamics of contemporary HTs in real-life clinical practice.

Methods and results: The Survey comprised 24 questions, including single-choice, multiple-choice, and open-labeled formats. It addressed all cardiologists and associated specialists involved in the HT meetings via online platform. A total of 233 responses were collected from 48 countries, 203 (87%) from Europe. Most respondents were imaging specialists (38%) and general cardiologists (29%), with 85% actively engaged in HT meetings. Twelve distinct HT configurations were identified. Core HT members included general and interventional cardiologists, cardiac surgeons, and imaging specialists. Complex cases are usually discussed at HT meetings, and ESC guidelines serve as a guiding framework (87%). Leadership within HTs is inconsistent and regular HT audits are lacking in 53% of centers. The Heart Team predominantly focus on treatment planning (97%) rather than outcome review (45%) or education (36%). Key perceived benefits include structured decision-making (74%), optimized management of complex cases (69%), and reduced specialty bias (67%). Recognized barriers included scheduling constraints, resource limitations, and communication inefficiencies.

Conclusion: This survey shows the important role of multidisciplinary HTs in contemporary clinical practice but reveals several areas of potential improvement. Addressing common challenges could result in more efficient HT practices and improve the care of complex patient cases in various cardiology subspecialty areas.

Aims: 4D phase-contrast cardiovascular magnetic resonance (CMR) allows for non-invasive estimation of mean pulmonary artery pressure (mPAP) by estimating the duration of pathological vortex persistence in the main pulmonary artery. This has previously been achieved with compressed sensing acceleration of a multiple 2D (CS-M2D) flow sequence, but acquisition using a true time-resolved 3D excitation (CS-4D) offers theoretical advantages including spatiotemporal coherence. This study aimed to validate a state-of-the-art CS-4D sequence with a previously utilized CS-M2D sequence for estimating mPAP, comparing both to right heart catheterization (RHC).

Methods and results: The study included patients clinically referred for CMR (n = 45), of which a subgroup (n = 20) had prior mPAP of >16 mmHg confirmed by RHC. CMR was performed at 1.5T using CS-M2D and CS-4D sequences covering the main pulmonary artery. mPAP was estimated using a previously published linear relationship between vortex duration and mPAP. Agreement between CS-M2D and CS-4D estimates was quantified, including analysis of intra- and interobserver variabilities. CS-M2D and CS-4D both had average scan durations under 3 min (175 ± 36 and 135 ± 34 s, respectively). Estimated mPAP by CS-4D and CS-M2D were strongly correlated (R ² = 0.93, P < 0.001), with negligible mean ± SD bias (0.0 ± 2.7 mmHg) and good reproducibility. There was excellent agreement with RHC for both CS-M2D (R ² = 0.92, P < 0.001, bias 0.6 ± 3.1 mmHg) and CS-4D (R ² = 0.86, P < 0.001, bias 1.1 ± 4.5 mmHg).

Conclusion: CS-4D and CS-M2D sequences yield interchangeable estimations of mPAP, with excellent agreement to invasive RHC. Both be acquired in a scan time applicable to clinical workflow, offering promising tools for non-invasive mPAP estimation in clinical practice.

Congenital heart disease (CHD), the most common congenital malformation worldwide, affects approximately 8-10 per 1000 live births. Despite major advances in diagnosis and treatment, significant disparities remain between high- and low-resource settings, with a substantial impact on survival and long-term outcomes. The Aesculapius Project was conceived to address these inequalities by employing advanced imaging and three-dimensional (3D) printing as educational tools to enhance paediatric cardiac surgery training. Initiated by the humanitarian foundations Bambini Cardiopatici nel Mondo and European Heart for Children, the program offers free training to early-career surgeons from resource-limited countries. Patient-specific 3D cardiac models are generated from computed tomography (CT) and magnetic resonance imaging (MRI) data and used in structured courses that combine lectures, supervised hands-on surgical simulations, and remote mentorship. To date, 81 physicians from 16 countries have participated in the program, performing 10-20 simulated procedures on complex CHD models under expert supervision. Technical performance scores improved by an average of 30%, and participants emphasized the educational value of repeated supervised practice and video-assisted review. The Aesculapius Project demonstrates that 3D anatomical models offer an ethical and effective platform for surgical education, representing a concrete step toward expanding access to high-quality paediatric cardiac surgery training in resource-limited settings.

Aims: Myocardial strain is a powerful, non-invasive diagnostic and prognostic marker in patients with heart disease. However, its applicability is hindered by uncertain repeatability, particularly for segmental values. This study measures the repeatability of myocardial strain across eight imaging methods.

Methods and results: In this prospective study, 20 healthy volunteers (aged 34 $\pm$ 8, 14 men) were recruited and scanned twice with eight strain imaging protocols: cardiac magnetic resonance (CMR) at 1.5T and 3T with cine, tagging, and displacement encoding with stimulated echoes (DENSE) sequences, and 2D and 3D echocardiography (Echo). Global and segmental strains were quantified from each scan. Inter-scan repeatability was assessed with the coefficient of variation (CoV), intraclass correlation coefficient, and Bland-Altman analysis.

Results: Inter-scan repeatability of global strains ranged from excellent to fair (CoV ≤ 20%) depending on protocol. Using CMR feature tracking at 1.5T, relative global longitudinal strain (GLS) changes exceeding 11.2% are unlikely to be caused by measurement variability alone; this figure is 5.5% for 2D echocardiography. Segmental strain values frequently had poor repeatability (CoV > 20%), particularly for longitudinal and radial strains.

Conclusion: Imaging protocols including CMR and Echo can measure global strain parameters with fair repeatability, but segmental strain values are unreliable. Future work should aim to improve the repeatability of segmental strain values, particularly longitudinal strain.

Aims: Heart transplantation is a critical life-saving procedure for patients with end-stage heart failure. However, predicting postoperative mortality remains challenging. The aim of this study is to examine the effectiveness of machine learning (ML) models for predicting 1-year mortality among heart transplant recipients in Saudi Arabia.

Methods and results: A retrospective observational study was conducted using data from King Faisal Specialist Hospital & Research Centre, a large tertiary hospital in Saudi Arabia, that included all heart transplant cases from January 2007 to December 2022. We evaluate and compare the accuracy of support vector machine (SVM) and logistic regression (LR) models in predicting 1-year mortality. We also identify key predictive variables influencing mortality rates among recipients. SVM and LR models were developed and compared using accuracy, precision, recall, F1 score, and area under the receiver operating characteristic curve as performance metrics. The study analysed data from 419 patients, revealing that ischaemia time, devices like left ventricle assist device, extracorporeal membrane oxygenation, and body mass index (BMI) were significant mortality predictors. The LR model showed a testing accuracy of 96.43%, with weight and BMI having the strongest influence on mortality prediction. The SVM model had a testing accuracy of 95.24%, demonstrating consistent performance across dataset.

Conclusion: The findings indicate that ML models, particularly SVM and LR, are effective in predicting 1-year mortality post-heart transplantation as well as identifying significant predictors of mortality. This research contributes to the global knowledge in heart transplant and highlights the importance of new technologies in tailoring healthcare strategies for the Saudi population.

Aims: Non-invasive estimation of left ventricular pressure (LVP) is crucial for managing cardiovascular diseases such as heart failure and myocardial infarction (MI). Current clinical practices rely on invasive catheterization, limiting its feasibility for routine or longitudinal monitoring. This study evaluates the accuracy of a novel LVP reconstruction algorithm in preclinical (rat) experiments.

Methods and results: Using a standard coronary occlusion/reperfusion model (n = 39 rats), we validated our algorithm across three physiological states: baseline, myocardial ischaemia, and MI. LVP waveforms were reconstructed using only carotid pressure waveforms and echocardiographic measurements. Algorithm performance was assessed by comparing reconstructed LVP waveforms to invasively measured LVP, using key haemodynamic metrics such as left ventricular end-diastolic pressure (LVEDP) and the subendocardial viability ratio (SEVR). Agreements between waveforms were assessed using intraclass correlation coefficients (ICC), normalized Euclidean distance (NED), and differences in harmonic modulus. The algorithm accurately estimated LVEDP across all physiological states (mean absolute error: 1.5 mmHg), with strong correlation to invasively measured LVEDPs (r = 0.91). Predicted SEVR also showed strong agreement with measured values (r = 0.96). The algorithm captured the expected LVEDP elevation and SEVR reduction during myocardial ischaemia, and the metric's partial recovery after reperfusion. Waveform-level agreement demonstrated near-perfect alignment, with high ICC (98.5%), low NED (0.062), and minimal harmonic modulus differences (0.043) for all tested cases.

Conclusion: This study demonstrates that LVP can be accurately reconstructed using the proposed algorithm in rats. Our algorithm reliably captured key LVP metrics and waveform features across varying physiological states, supporting its potential for cardiac monitoring.

Interventional cardiac magnetic resonance imaging (iCMR) offers distinct advantages for guiding complex cardiac procedures, including 3D visualization, soft tissue characterization, and avoidance of ionizing radiation. Transseptal puncture (TSP), essential for left heart access, poses specific challenges under MR-guidance. The development of MR-compatible TSP sets comprising non-ferromagnetic sheaths, dilators, and needles, represents a major step toward safe execution of TSP in the MRI environment. This report provides practical, step-by-step guidance for MR-guided TSP, focusing on imaging strategies and integration of advanced 2D and 3D navigation tools. Real-time cine imaging in dedicated planes enables precise localization of the fossa ovalis, confirmation of septal tenting, and avoidance of adjacent structures. Complementary use of a vendor-neutral MR-compatible 3D navigation system allows dynamic catheter tracking within a segmented static 3D anatomical shell, enhancing spatial orientation and procedural accuracy. Feasibility was demonstrated in a porcine model, where an MR-compatible sheath and trackable dilator were successfully navigated to the interatrial septum and TSP was achieved, enabling left atrial (LA) access. Subsequent mapping confirmed catheter positioning within the LA. Remaining challenges include limited guidewire visibility, low image temporal resolution compared with fluoroscopy, and the investigational status of current MR-compatible TSP sets. These factors must be addressed before clinical translation. In conclusion, MR-guided TSP using dedicated imaging planes and MR-compatible devices is technically feasible and may facilitate future radiation-free left heart interventions. Continued device refinement, including improved passive instrument visibility and active tracking technologies, faster real-time cine imaging, and regulatory approval are critical for safe and widespread clinical adoption.

Aims: Left atrial volume (LAV) is a recognized prognostic marker of cardiovascular events. However, normal LAV thresholds on cardiac computed tomography angiography (CCTA) remain poorly defined, and the optimal assessment method is unclear. Our aim was to determine normal reference values of maximal systolic LAV (LAVmax) and ventricular dimensions normalized by age, sex, and body surface area (BSA) from CCTA by using dedicated semi-automated analysis software.

Methods and results: This single-centre retrospective study included 250 healthy subjects with no cardiac history or significant CCTA abnormalities, stratified by sex and age. LAVmax was measured using both 3D and area-length methods, and all other cardiac chambers were analysed with dedicated 3D semi-automated software (Vitrea^®). LAVmax increased significantly with age in both sexes but showed no sex difference when indexed to BSA. The 3D volumetric method was more reproducible (r = 0.86, P < 0.001) and yielded larger values compared with area-length method. Reference values for LAVmax and all cardiac chambers were provided for both sexes and each age group. Age, in concert with sex, was associated with significant differences in RV end-diastolic volume and LV ejection fraction (P-values 0.027 and 0.03).

Conclusion: Indexed LAVmax was not significantly different across sexes but increased with age. LAVmax can be reliably reported from CCTA datasets, with 3D volumetric method providing the largest and most reproducible values. Normal values for all cardiac chambers according to age categories and sex were also provided. These normative values enhance the clinical utility of routine CCTA beyond coronary imaging.