Myocardial Late Contrast Enhancement CT in Troponin-Positive Acute Chest Pain Syndrome

Imaging for the assessment of the arrhythmogenic potential of mitral valve prolapse

Mitral valve prolapse (MVP) is the most common valve disease in the western world and recently emerged as a possible substrate for sudden cardiac death (SCD). It is estimated an annual risk of sudden cardiac death of 0.2 to 1.9% mostly caused by complex ventricular arrhythmias (VA). Several mechanisms have been recognized as potentially responsible for arrhythmia onset in MVP, resulting from the combination of morpho-functional abnormality of the mitral valve, structural substrates (regional myocardial hypertrophy, fibrosis, Purkinje fibers activity, inflammation), and mechanical stretch. Echocardiography plays a central role in MVP diagnosis and assessment of severity of regurgitation. Several abnormalities detectable by echocardiography can be prognostic for the occurrence of VA, from morphological alteration including leaflet redundancy and thickness, mitral annular dilatation, and mitral annulus disjunction (MAD), to motion abnormalities detectable with "Pickelhaube" sign. Additionally, speckle-tracking echocardiography may identify MVP patients at higher risk for VA by detection of increased mechanical dispersion. On the other hand, cardiac magnetic resonance (CMR) has the capability to provide a comprehensive risk stratification combining the identification of morphological and motion alteration with the detection of myocardial replacement and interstitial fibrosis, making CMR an ideal method for arrhythmia risk stratification in patients with MVP. Finally, recent studies have suggested a potential role in risk stratification of new techniques such as hybrid PET-MR and late contrast enhancement CT. The purpose of this review is to provide an overview of the mitral valve prolapse syndrome with a focus on the role of imaging in arrhythmic risk stratification. CLINICAL RELEVANCE STATEMENT: Mitral valve prolapse is the most frequent valve condition potentially associated with arrhythmias. Imaging has a central role in the identification of anatomical, functional, mechanical, and structural alterations potentially associated with a higher risk of developing complex ventricular arrhythmia and sudden cardiac death. KEY POINTS: • Mitral valve prolapse is a common valve disease potentially associated with complex ventricular arrhythmia and sudden cardiac death. • The mechanism of arrhythmogenesis in mitral valve prolapse is complex and multifactorial, due to the interplay among multiple conditions including valve morphological alteration, mechanical stretch, myocardial structure remodeling with fibrosis, and inflammation. • Cardiac imaging, especially echocardiography and cardiac magnetic resonance, is crucial in the identification of several features associated with the potential risk of serious cardiac events. In particular, cardiac magnetic resonance has the advantage of being able to detect myocardial fibrosis which is currently the strongest prognosticator.

Cardiac computed tomography with late contrast enhancement: A review

Cardiac computed tomography (CCT) has assumed an increasingly significant role in the evaluation of coronary artery disease (CAD) during the past few decades, whereas cardiovascular magnetic resonance (CMR) remains the gold standard for myocardial tissue characterization. The discovery of late myocardial enhancement following intravenous contrast administration dates back to the 1970s with ex-vivo CT animal investigations; nevertheless, the clinical application of this phenomenon for cardiac tissue characterization became prevalent for CMR imaging far earlier than for CCT imaging. Recently the technical advances in CT scanners have made it possible to take advantage of late contrast enhancement (LCE) for tissue characterization in CCT exams. Moreover, the introduction of extracellular volume calculation (ECV) on cardiac CT images combined with the possibility of evaluating cardiac function in the same exam is making CCT imaging a multiparametric technique more and more similar to CMR. The aim of our review is to provide a comprehensive overview on the role of CCT with LCE in the evaluation of a wide range of cardiac conditions.

Coronary computed tomography angiography for clinical practice

Coronary artery disease (CAD) is a common condition caused by the accumulation of atherosclerotic plaques. It can be classified into stable CAD or acute coronary syndrome. Coronary computed tomography angiography (CCTA) has a high negative predictive value and is used as the first examination for diagnosing stable CAD, particularly in patients at intermediate-to-high risk. CCTA is also adopted for diagnosing acute coronary syndrome, particularly in patients at low-to-intermediate risk. Myocardial ischemia does not always co-exist with coronary artery stenosis, and the positive predictive value of CCTA for myocardial ischemia is limited. However, CCTA has overcome this limitation with recent technological advancements such as CT perfusion and CT-fractional flow reserve. In addition, CCTA can be used to assess coronary artery plaques. Thus, the indications for CCTA have expanded, leading to an increased demand for radiologists. The CAD reporting and data system (CAD-RADS) 2.0 was recently proposed for standardizing CCTA reporting. This RADS evaluates and categorizes patients based on coronary artery stenosis and the overall amount of coronary artery plaque and links this to patient management. In this review, we aimed to review the major trials and guidelines for CCTA to understand its clinical role. Furthermore, we aimed to introduce the CAD-RADS 2.0 including the assessment of coronary artery stenosis, plaque, and other key findings, and highlight the steps for CCTA reporting. Finally, we aimed to present recent research trends including the perivascular fat attenuation index, artificial intelligence, and the advancements in CT technology.

Clinical Utility of Computed Tomography-Derived Myocardial Extracellular Volume Fraction: A Systematic Review and Meta-Analysis

BACKGROUND

Computed tomography (CT)-derived extracellular volume fraction (ECV) is a noninvasive method to quantify myocardial fibrosis. Although studies suggest CT is a suitable measure of ECV, clinical use remains limited.

OBJECTIVES

A meta-analysis was performed to determine the clinical value of CT-derived ECV in cardiovascular diseases.

METHODS

Electronic database searches of PubMed, Web of Science Core Collection, Cochrane advanced search, and EMBASE were performed. The most pivotal analysis entailed the comparison of ECV ascertained through CT-ECV among the control, aortic stenosis, and cardiac amyloidosis cohorts. The diagnostic test accuracy for detecting cardiac amyloidosis was assessed using summary receiver-operating characteristics curve.

RESULTS

Pooled CT-derived ECV values were 28.5% (95% CI: 27.3%-29.7%) in the control, 31.9% (95% CI: 30.2%-33.8%) in the aortic stenosis, and 48.9% (95% CI: 44.5%-53.3%) in the cardiac amyloidosis group. ECV was significantly elevated in aortic stenosis (P = 0.002) (vs controls) but further elevated in cardiac amyloidosis (P < 0.001) (vs aortic stenosis). CT-derived ECV had a high diagnostic accuracy for cardiac amyloidosis, with sensitivity of 92.8% (95% CI: 86.7%-96.2%), specificity of 84.8% (95% CI: 68.6%-93.4%), and area under the summary receiver-operating characteristic curve of 0.94 (95% CI: 0.88-1.00).

CONCLUSIONS

This study is the first comprehensive systematic review and meta-analysis of CT-derived ECV evaluation in cardiac disease. The high diagnostic accuracy of CT-ECV suggests the usefulness of CT-ECV in the diagnosis of cardiac amyloidosis in preoperative CT planning for transcatheter aortic valve replacement.

Imaging biomarkers in cardiac CT: moving beyond simple coronary anatomical assessment

Cardiac computed tomography angiography (CCTA) is considered the standard non-invasive tool to rule-out obstructive coronary artery disease (CAD). Moreover, several imaging biomarkers have been developed on cardiac-CT imaging to assess global CAD severity and atherosclerotic burden, including coronary calcium scoring, the segment involvement score, segment stenosis score and the Leaman-score. Myocardial perfusion imaging enables the diagnosis of myocardial ischemia and microvascular damage, and the CT-based fractional flow reserve quantification allows to evaluate non-invasively hemodynamic impact of the coronary stenosis. The texture and density of the epicardial and perivascular adipose tissue, the hypodense plaque burden, the radiomic phenotyping of coronary plaques or the fat radiomic profile are novel CT imaging features emerging as biomarkers of inflammation and plaque instability, which may implement the risk stratification strategies. The ability to perform myocardial tissue characterization by extracellular volume fraction and radiomic features appears promising in predicting arrhythmogenic risk and cardiovascular events. New imaging biomarkers are expanding the potential of cardiac CT for phenotyping the individual profile of CAD involvement and opening new frontiers for the practice of more personalized medicine.

Value of a short non-contrast CMR protocol in MINOCA

OBJECTIVES

To evaluate the diagnostic performance of a short non-contrast CMR (ShtCMR) protocol relative to a matched standard comprehensive CMR (StdCMR) protocol in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA).

METHODS

This multicenter retrospective study included patients with a working diagnosis of MINOCA who underwent a StdCMR between January 2019 and December 2020. An expert and a non-expert reader performed a blinded reading with the ShtCMR (long-axis cine images, T2w-STIR, T1- and T2-mapping). A consensus reading of the StdCMR (reference standard) was performed at least 3 months after the ShtCMR reading session. Readers were asked to report the following: (1) diagnosis; (2) level of confidence in their diagnosis with the ShtCMR; (3) number of myocardial segments involved, and (4) functional parameters.

RESULTS

A total of 179 patients were enrolled. The ShtCMR lasted 21 ± 9 min and the StdCMR 45 ± 11 min (p < 0.0001). ShtCMR allowed reaching the same diagnosis as StdCMR in 85% of patients when interpreted by expert readers (rising from 66% for poor confidence to 99% for good, p = 0.0001) and in 73% (p = 0.01) by non-expert ones (60% for poor vs 89% for good confidence, p = 0.0001). Overall, the ShtCMR overestimated the ejection fraction, underestimated cardiac volumes (p < 0.01), and underestimated the number of segments involved by pathology (p = 0.0008) when compared with the StdCMR.

CONCLUSION

The ShtCMR was found to be a debatable alternative to the StdCMR in patients with MINOCA. Nevertheless, when an experienced reader reaches a good or very good diagnostic confidence using the ShtCMR, the reader may choose to stop the examination, reducing the length of the CMR without affecting the patient's diagnosis.

CLINICAL RELEVANCE STATEMENT

A short non-contrast CMR protocol may be a viable alternative to standard protocols in selected CMR studies of patients with MINOCA, allowing for faster diagnosis while reducing time and resources and increasing the number of patients who can be scanned.

KEY POINTS

• The ShtCMR lasted 21 ± 9 min and the StdCMR 45 ± 11 min (p < 0.0001). • In 57% of patients with MINOCA, the experienced reader considers that contrast medium is probably not necessary for diagnosis without affecting the patient's diagnosis (99% of agreement rate between ShtCMR and StdCMR).

Myocardial late enhancement and extracellular volume with single-energy, dual-energy, and photon-counting computed tomography

Computed tomography late enhancement (CT-LE) is emerging as a non-invasive technique for cardiac diagnosis with wider accessibility compared to MRI, despite its typically lower contrast-to-noise ratio. Optimizing CT-LE image quality necessitates a thorough methodology addressing contrast administration, timing, and radiation dose, alongside a robust understanding of extracellular volume (ECV) quantification methods. This review summarizes CT-LE protocols, clinical utility, and advances in ECV measurement through both single-energy and dual-energy CT. It also highlights photon-counting detector CT technology as an innovative means to potentially improve image quality and reduce radiation exposure.

Cardiovascular magnetic resonance (CMR) and positron emission tomography (PET) imaging in the diagnosis and follow-up of patients with acute myocarditis and chronic inflammatory cardiomyopathy : A review paper with practical recommendations on behalf of the European Society of Cardiovascular Radiology (ESCR)

Advanced cardiac imaging techniques such as cardiovascular magnetic resonance (CMR) and positron emission tomography (PET) are widely used in clinical practice in patients with acute myocarditis and chronic inflammatory cardiomyopathies (I-CMP). We aimed to provide a review article with practical recommendations from the European Society of Cardiovascular Radiology (ESCR), in order to guide physicians in the use and interpretation of CMR and PET in clinical practice both for acute myocarditis and follow-up in chronic forms of I-CMP.

Myocardial extracellular volume quantification with computed tomography-current status and future outlook

Non-invasive quantification of the extracellular volume (ECV) is a method for the evaluation of focal and diffuse myocardial fibrosis, potentially obviating the need for invasive endomyocardial biopsy. While ECV quantification with cardiac magnetic resonance imaging (ECVMRI) is already an established method, ECV quantification with CT (ECVCT) is an attractive alternative to ECVMRI, similarly using the properties of extracellular contrast media for ECV calculation. In contrast to ECVMRI, ECVCT provides a more widely available, cheaper and faster tool for ECV quantification and allows for ECV calculation also in patients with contraindications for MRI. Many studies have already shown a high correlation between ECVCT and ECVMRI and accumulating evidence suggests a prognostic value of ECVCT quantification in various cardiovascular diseases. Adding a late enhancement scan (for dual energy acquisitions) or a non-enhanced and late enhancement scan (for single-energy acquisitions) to a conventional coronary CT angiography scan improves risk stratification, requiring only minor adaptations of the contrast media and data acquisition protocols and adding only little radiation dose to the entire scan.Critical relevance statementThis article summarizes the technical principles of myocardial extracellular volume (ECV) quantification with CT, reviews the literature comparing ECVCT with ECVMRI and histopathology, and reviews the prognostic value of myocardial ECV quantification for various cardiovascular disease.Key points• Non-invasive quantification of myocardial fibrosis can be performed with CT.• Myocardial ECV quantification with CT is an alternative in patients non-eligible for MRI.• Myocardial ECV quantification with CT strongly correlates with ECV quantification using MRI.• Myocardial ECV quantification provides incremental prognostic information for various pathologies affecting the heart (e.g., cardiac amyloidosis).

Frequency Domain Analysis of Endocardial Electrograms for Detection of Nontransmural Myocardial Fibrosis in Nonischemic Cardiomyopathy

BACKGROUND

Voltage mapping in nonischemic cardiomyopathy can fail to identify midmyocardial substrate for ventricular arrhythmias, an important cause of ablation failure.

OBJECTIVES

The aim of this study was to assess whether frequency domain analysis of endocardial left ventricular electrograms (EGMs) can better predict the presence of midmyocardial fibrosis (MMF) compared with voltage amplitude.

METHODS

Nonischemic cardiomyopathy patients undergoing ventricular tachycardia ablation with registered preprocedural cardiac computed tomography and late iodine enhancement were included. Presence of fibrosis at each EGM site was assessed. Bipolar and unipolar EGMs were transformed to the frequency domain using multitaper spectral analysis. Singular value decomposition of the EGM frequency spectrum was used within a supervised machine learning process to select features to predict the presence of MMF and compare against predictions using voltage amplitude.

RESULTS

Thirteen patients were included (median age 57 years [IQR: 28-73 years], median ejection fraction 40% [IQR: 15%-57%]). A total of 6,015 EGM pairs were processed: 2,459 EGM pairs in MMF areas and 3,556 EGM pairs in non-MMF areas. Supervised classifiers were trained with stratified k-fold cross-validation within patients. The distribution of mean area under the curve metrics using frequency features, f, was significantly greater than voltage feature area under the curve metrics, v, (mean f = 0.841 [95% CI: 0.789-0.884] vs mean v = 0.591 [95% CI: 0.530-0.658]; P < 0.001), indicating that frequency-trained classifiers better predicted the presence of MMF.

CONCLUSIONS

These data indicate the promising discriminatory value of endocardial EGM frequency content in the assessment of concealed myocardial substrate. Further studies are needed to investigate the importance of the specific frequency features identified.

Campylobacter myocarditis: a rare but potential sequelae of Campylobacter jejuni

Myocarditis is an inflammatory cardiomyopathy with a diverse range of both infective and non-infective causes. It is an important cause of dilated cardiomyopathy worldwide, with a variable clinical course ranging from a mild self-limiting illness to fulminant cardiogenic shock requiring mechanical circulatory support and cardiac transplantation. Here, we describe a case of acute myocarditis secondary to Campylobacter jejuni infection in a man in his 50s who presented with an acute coronary syndrome following a recent gastrointestinal illness.

Dual-Source Photon-Counting Computed Tomography-Part I: Clinical Overview of Cardiac CT and Coronary CT Angiography Applications

The photon-counting detector (PCD) is a new computed tomography detector technology (photon-counting computed tomography, PCCT) that provides substantial benefits for cardiac and coronary artery imaging. Compared with conventional CT, PCCT has multi-energy capability, increased spatial resolution and soft tissue contrast with near-null electronic noise, reduced radiation exposure, and optimization of the use of contrast agents. This new technology promises to overcome several limitations of traditional cardiac and coronary CT angiography (CCT/CCTA) including reduction in blooming artifacts in heavy calcified coronary plaques or beam-hardening artifacts in patients with coronary stents, and a more precise assessment of the degree of stenosis and plaque characteristic thanks to its better spatial resolution. Another potential application of PCCT is the use of a double-contrast agent to characterize myocardial tissue. In this current overview of the existing PCCT literature, we describe the strengths, limitations, recent applications, and promising developments of employing PCCT technology in CCT.

Exploring the EVolution in PrognOstic CapabiLity of MUltisequence Cardiac MagneTIc ResOnance in PatieNts Affected by Takotsubo Cardiomyopathy Based on Machine Learning Analysis: Design and Rationale of the EVOLUTION Study

PURPOSE

Takotsubo cardiomyopathy (TTC) is a transient but severe acute myocardial dysfunction with a wide range of outcomes from favorable to life-threatening. The current risk stratification scores of TTC patients do not include cardiac magnetic resonance (CMR) parameters. To date, it is still unknown whether and how clinical, trans-thoracic echocardiography (TTE), and CMR data can be integrated to improve risk stratification.

METHODS

EVOLUTION (Exploring the eVolution in prognOstic capabiLity of mUlti-sequence cardiac magneTIc resOnance in patieNts affected by Takotsubo cardiomyopathy) is a multicenter, international registry of TTC patients who will undergo a clinical, TTE, and CMR evaluation. Clinical data including demographics, risk factors, comorbidities, laboratory values, ECG, and results from TTE and CMR analysis will be collected, and each patient will be followed-up for in-hospital and long-term outcomes. Clinical outcome measures during hospitalization will include cardiovascular death, pulmonary edema, arrhythmias, stroke, or transient ischemic attack.Clinical long-term outcome measures will include cardiovascular death, pulmonary edema, heart failure, arrhythmias, sudden cardiac death, and major adverse cardiac and cerebrovascular events defined as a composite endpoint of death from any cause, myocardial infarction, recurrence of TTC, transient ischemic attack, and stroke. We will develop a comprehensive clinical and imaging score that predicts TTC outcomes and test the value of machine learning models, incorporating clinical and imaging parameters to predict prognosis.

CONCLUSIONS

The main goal of the study is to develop a comprehensive clinical and imaging score, that includes TTE and CMR data, in a large cohort of TTC patients for risk stratification and outcome prediction as a basis for possible changes in patient management.

CT Extracellular Volume Fraction versus Myocardium-to-Lumen Signal Ratio for Cardiac Amyloidosis

Background Large studies on the diagnostic performance of CT-derived myocardial extracellular volume fraction (ECV) for detecting cardiac amyloidosis are lacking. A simple and practical index as a surrogate for CT ECV would be clinically useful. Purpose To compare the diagnostic performances between CT-derived myocardial ECV and myocardium-to-lumen signal ratio for the detection of cardiac amyloidosis in a large patient sample. Materials and Methods This retrospective study included patients who underwent CT ECV analysis because of suspected heart failure or cardiomyopathy between January 2018 and July 2021. CT ECV was quantified using routine pre-transcatheter aortic valve replacement planning cardiac CT, pre-atrial fibrillation ablation planning cardiac CT, or coronary CT angiography with the addition of unenhanced and delayed phase cardiac CT scans. The diagnostic performances of CT ECV and myocardium-to-lumen signal ratio in delayed phase cardiac CT (a simplified index not requiring unenhanced CT and hematocrit) for detecting cardiac amyloidosis were evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. Results Of 552 patients (mean age, 69 years ± 14 [SD]; 295 men), 41 had cardiac amyloidosis. The sensitivity of CT ECV for amyloidosis was 90% (37 of 41 patients [95% CI: 77, 97]), with a specificity of 92% (472 of 511 patients [95% CI: 90, 95]) and optimal ECV cutoff value of 37% (AUC, 0.97 [95% CI: 0.96, 0.99]). The sensitivity of myocardium-to-lumen signal ratio was 88% (36 of 41 patients [95% CI: 74, 96]), with a specificity of 92% (469 of 511 patients [95% CI: 89, 94]) and optimal myocardium-to-lumen signal ratio cutoff value of 0.87 (AUC, 0.96 [95% CI: 0.94, 0.97]; P = .27 for comparison with ECV). Conclusion CT-derived myocardial extracellular volume fraction and myocardium-to-lumen signal ratio showed comparable and excellent diagnostic performance in detecting cardiac amyloidosis in a large patient sample. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Williams in this issue.

Tricuspid Valve Geometrical Changes in Patients with Functional Tricuspid Regurgitation: Insights from a CT Scan Analysis Focusing on Commissures

BACKGROUND

Cardiac computed tomography (CT) provides important insights into the geometrical configuration of the tricuspid valve (TV). The purpose of the present study was to assess the geometrical changes of TV in patients with functional tricuspid regurgitation (TR) using novel CT scan parameters and to correlate these findings with echocardiography.

METHODS

This single-center study enrolled 86 patients undergoing cardiac CT and divided them into two groups according to the presence or not of severe TR (43 patients with TR ≥ 3+ and 43 controls). The measurements collected were as follows: TV annulus area and perimeter, septal-lateral and antero-posterior annulus diameters, eccentricity, distance between commissures, segment between the geometrical centroid and commissures, and the angles of commissures.

RESULTS

We found a significant correlation between all annulus measurements and the grade of TR, except in regard to angles. TR ≥ 3+ patients had significantly larger TV annulus area and perimeter, larger septal-lateral, and antero-posterior annulus dimensions, as well as larger commissural distance and centroid-commissural distance. In patients with TR ≥ 3+ and controls, the eccentricity index predicted a circular shape and an oval shape of the annulus, respectively.

CONCLUSIONS

These novel CT variables focusing on commissures increase the anatomical understanding of the TV apparatus and the TV geometrical changes in patients with severe functional TR.

Extracellular Volume Fraction by Computed Tomography Predicts Long-Term Prognosis Among Patients With Cardiac Amyloidosis

BACKGROUND

Light chain (AL) and transthyretin (ATTR) amyloid fibrils are deposited in the extracellular space of the myocardium, resulting in heart failure and premature mortality. Extracellular expansion can be quantified by computed tomography, offering a rapid, cheaper, and more practical alternative to cardiac magnetic resonance, especially among patients with cardiac devices or on renal dialysis.

OBJECTIVES

This study sought to investigate the association of extracellular volume fraction by computed tomography (ECV_CT), myocardial remodeling, and mortality in patients with systemic amyloidosis.

METHODS

Patients with confirmed systemic amyloidosis and varying degrees of cardiac involvement underwent electrocardiography-gated cardiac computed tomography. Whole heart and septal ECV_CT was analyzed. All patients also underwent clinical assessment, electrocardiography, echocardiography, serum amyloid protein component, and/or technetium-99m (^99mTc) 3,3-diphosphono-1,2-propanodicarboxylic acid scintigraphy. ECV_CT was compared across different extents of cardiac infiltration (ATTR Perugini grade/AL Mayo stage) and evaluated for its association with myocardial remodeling and all-cause mortality.

RESULTS

A total of 72 patients were studied (AL: n = 35, ATTR: n = 37; median age: 67 [IQR: 59-76] years, 70.8% male). Mean septal ECV_CT was 42.7% ± 13.1% and 55.8% ± 10.9% in AL and ATTR amyloidosis, respectively, and correlated with indexed left ventricular mass (r = 0.426; P < 0.001), left ventricular ejection fraction (r = 0.460; P < 0.001), N-terminal pro-B-type natriuretic peptide (r = 0.563; P < 0.001), and high-sensitivity troponin T (r = 0.546; P < 0.001). ECV_CT increased with cardiac amyloid involvement in both AL and ATTR amyloid. Over a mean follow-up of 5.3 ± 2.4 years, 40 deaths occurred (AL: n = 14 [35.0%]; ATTR: n = 26 [65.0%]). Septal ECV_CT was independently associated with all-cause mortality in ATTR (not AL) amyloid after adjustment for age and septal wall thickness (HR: 1.046; 95% CI: 1.003-1.090; P = 0.037).

CONCLUSIONS

Cardiac amyloid burden quantified by ECV_CT is associated with adverse cardiac remodeling as well as all-cause mortality among ATTR amyloid patients. ECV_CT may address the need for better identification and risk stratification of amyloid patients, using a widely accessible imaging modality.

Multimodality imaging in acute myocarditis

The diagnosis of acute myocarditis often involves several noninvasive techniques that can provide information regarding volumes, ejection fraction, and tissue characterization. In particular, echocardiography is extremely helpful for the evaluation of biventricular volumes, strain and ejection fraction. Cardiac magnetic resonance, beyond biventricular volumes, strain, and ejection fraction allows to characterize myocardial tissue providing information regarding edema, hyperemia, and fibrosis. Contemporary cardiac computed tomography angiography (CCTA) can not only be extremely important for the assessment of coronary arteries, pulmonary arteries and aorta but also tissue characterization using CCTA can be an additional tool that can explain chest pain with a diagnosis of myocarditis.

Multimodality Imaging of Sudden Cardiac Death and Acute Complications in Acute Coronary Syndrome

Sudden cardiac death (SCD) is a potentially fatal event usually caused by a cardiac arrhythmia, which is often the result of coronary artery disease (CAD). Up to 80% of patients suffering from SCD have concomitant CAD. Arrhythmic complications may occur in patients with acute coronary syndrome (ACS) before admission, during revascularization procedures, and in hospital intensive care monitoring. In addition, about 20% of patients who survive cardiac arrest develop a transmural myocardial infarction (MI). Prevention of ACS can be evaluated in selected patients using cardiac computed tomography angiography (CCTA), while diagnosis can be depicted using electrocardiography (ECG), and complications can be evaluated with cardiac magnetic resonance (CMR) and echocardiography. CCTA can evaluate plaque, burden of disease, stenosis, and adverse plaque characteristics, in patients with chest pain. ECG and echocardiography are the first-line tests for ACS and are affordable and useful for diagnosis. CMR can evaluate function and the presence of complications after ACS, such as development of ventricular thrombus and presence of myocardial tissue characterization abnormalities that can be the substrate of ventricular arrhythmias.

Phenotyping the hypertensive heart

Arterial hypertension remains the most frequent cardiovascular (CV) risk factor, and is responsible for a huge global burden of disease. Echocardiography is the first-line imaging method for the evaluation of cardiac damage in hypertensive patients and novel techniques, such as 2D and D speckle tracking and myocardial work, provide insight in subclinical left ventricular (LV) impairment that would not be possible to detect with conventional echocardiography. The structural, functional, and mechanical cardiac remodelling that are detected with imaging are intermediate stages in the genesis of CV events, and initiation or intensification of antihypertensive therapy in response to these findings may prevent or delay progressive remodelling and CV events. However, LV remodelling—especially LV hypertrophy—is not specific to hypertensive heart disease (HHD) and there are circumstances when other causes of hypertrophy such as athlete heart, aortic stenosis, or different cardiomyopathies need exclusion. Tissue characterization obtained by LV strain, cardiac magnetic resonance, or computed tomography might significantly help in the distinction of different LV phenotypes, as well as being sensitive to subclinical disease. Selective use of multimodality imaging may therefore improve the detection of HHD and guide treatment to avoid disease progression. The current review summarizes the advanced imaging tests that provide morphological and functional data about the hypertensive cardiac injury.

Advanced cardiac imaging in the spectrum of COVID-19 related cardiovascular involvement

Cardiovascular involvement is a common complication of COVID-19 infection and is associated to increased risk of unfavorable outcome. Advanced imaging modalities (coronary CT angiography and Cardiac Magnetic Resonance) play a crucial role in the diagnosis, follow-up and risk stratification of patients affected by COVID-19 pneumonia with suspected cardiovascular involvement. In the present manuscript we firstly review current knowledge on the mechanisms by which SARS-CoV-2 can trigger endothelial and myocardial damage. Secondly, the implications of the cardiovascular damage on patient's prognosis are presented. Finally, we provide an overview of the main findings at advanced cardiac imaging characterizing COVID-19 in the acute setting, in the post-acute syndrome, and after vaccination, emphasizing the potentiality of CT and CMR, the indication and their clinical implications.

Symptomatic Young Adults with ST-Segment Elevation-Acute Coronary Syndrome or Myocarditis: The Three-Factor Diagnostic Model

Myocarditis may mimic myocardial infarction (MI) due to a similar clinical presentation, including chest pain, electrocardiography changes, and laboratory findings. The purpose of the study was to investigate the diagnostic value of clinical, laboratory, and electrocardiography characteristics of patients with acute coronary syndrome - like myocarditis and MI. We analysed 90 patients (≤45 years old) with an initial diagnosis of ST-segment elevation myocardial infarction; 40 patients (44.4%), through the use of cardiac magnetic resonance, were confirmed to have myocarditis, and 50 patients (55.6%) were diagnosed with MI. Patients with myocarditis were younger and had fewer cardiovascular risk factors than those with MI. The cutoff value distinguishing between myocarditis and MI was defined as the age of 36 years. The history of recent infections (82.5% vs. 6%) and C-reactive protein (CRP) levels on admission (Me 45.9 vs. 3.4) was more associated with myocarditis. Further, the QTc interval was inversely correlated with the echocardiographic ejection fraction in both groups but was significantly longer in patients with MI. Non-invasive diagnostics based on clinical features and laboratory findings are basic but still essential tools for differentiation between MI and myocarditis. The three-factor model including the criteria of age, abnormal CRP, and history of recent infections might become a valuable clinical indication.