Coronary Artery Disease Assessment via On-Site CT Fractional Flow Reserve in Patients Undergoing Transcatheter Aortic Valve Replacement

Purpose To examine the clinical feasibility of workstation-based CT fractional flow reserve (CT-FFR) for coronary artery disease (CAD) evaluation during preprocedural planning in patients undergoing transcatheter aortic valve replacement (TAVR). Materials and Methods In this retrospective single-center study, 434 patients scheduled for TAVR between 2018 and 2020 were screened for study inclusion; a relevant proportion of patients (35.0% [152 of 434]) was not suitable for evaluation due to insufficient imaging properties. A total of 112 patients (mean age, 82.1 years ± 6.7 [SD]; 58 [52%] men) were included in the study. Invasive angiography findings, coronary CT angiography results, and Agatston score were acquired and compared with on-site CT-FFR computation for evaluation of CAD and prediction of major adverse cardiovascular events (MACE) within a 24-month follow-up. Results Hemodynamic relevant CAD, as suggested by CT-FFR of 0.80 or less, was found in 41 of 70 (59%) patients with stenosis of 50% or more. MACE occurred in 23 of 112 (20.5%) patients, from which 14 of 23 had stenoses with CT-FFR of 0.80 or less (hazard ratio [HR], 3.33; 95% CI: 1.56, 7.10; P = .002). CT-FFR remained a significant predictor of MACE after inclusion in a multivariable model with relevant covariables (HR, 2.89; 95% CI: 1.22, 6.86; P = .02). An Agatston score of 1000 Agatston units or more (HR, 2.25; 95% CI: 0.98, 5.21; P = .06) and stenoses of 50% or more determined via invasive angiography (HR, 0.94; 95% CI: 0.41, 2.17; P = .88) were not significant predictors of MACE. Conclusion Compared with conventional CAD markers, CT-FFR better predicted adverse outcomes after TAVR. A relevant portion of the screened cohort, however, was not suitable for CT-based CAD evaluation. Keywords: CT, Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR), Cardiac, Coronary Arteries, Outcomes Analysis © RSNA, 2024 See also the commentary by Weir-McCall and Pugliese in this issue.

DNMT3A clonal hematopoiesis-driver mutations induce cardiac fibrosis by paracrine activation of fibroblasts

Hematopoietic mutations in epigenetic regulators like DNA methyltransferase 3 alpha (DNMT3A), play a pivotal role in driving clonal hematopoiesis of indeterminate potential (CHIP), and are associated with unfavorable outcomes in patients suffering from heart failure (HF). However, the precise interactions between CHIP-mutated cells and other cardiac cell types remain unknown. Here, we identify fibroblasts as potential partners in interactions with CHIP-mutated monocytes. We used combined transcriptomic data derived from peripheral blood mononuclear cells of HF patients, both with and without CHIP, and cardiac tissue. We demonstrate that inactivation of DNMT3A in macrophages intensifies interactions with cardiac fibroblasts and increases cardiac fibrosis. DNMT3A inactivation amplifies the release of heparin-binding epidermal growth factor-like growth factor, thereby facilitating activation of cardiac fibroblasts. These findings identify a potential pathway of DNMT3A CHIP-driver mutations to the initiation and progression of HF and may also provide a compelling basis for the development of innovative anti-fibrotic strategies.

The diagnostic performance of quantitative flow ratio and perfusion imaging in patients with prior coronary artery disease

AIMS

In chronic coronary syndrome (CCS) patients with documented coronary artery disease (CAD), ischaemia detection by myocardial perfusion imaging (MPI) and an invasive approach are viable diagnostic strategies. We compared the diagnostic performance of quantitative flow ratio (QFR) with single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (CMR) in patients with prior CAD [previous percutaneous coronary intervention (PCI) and/or myocardial infarction (MI)].

METHODS AND RESULTS

This PACIFIC-2 sub-study evaluated 189 CCS patients with prior CAD for inclusion. Patients underwent SPECT, PET, and CMR followed by invasive coronary angiography with fractional flow reserve (FFR) measurements of all major coronary arteries (N = 567), except for vessels with a sub-total or chronic total occlusion. Quantitative flow ratio computation was attempted in 488 (86%) vessels with measured FFR available (FFR ≤0.80 defined haemodynamically significant CAD). Quantitative flow ratio analysis was successful in 334 (68%) vessels among 166 patients and demonstrated a higher accuracy (84%) and sensitivity (72%) compared with SPECT (66%, P < 0.001 and 46%, P = 0.001), PET (65%, P < 0.001 and 58%, P = 0.032), and CMR (72%, P < 0.001 and 33%, P < 0.001). The specificity of QFR (87%) was similar to that of CMR (83%, P = 0.123) but higher than that of SPECT (71%, P < 0.001) and PET (67%, P < 0.001). Lastly, QFR exhibited a higher area under the receiver operating characteristic curve (0.89) than SPECT (0.57, P < 0.001), PET (0.66, P < 0.001), and CMR (0.60, P < 0.001).

CONCLUSION

QFR correlated better with FFR in patients with prior CAD than MPI, as reflected in the higher diagnostic performance measures for detecting FFR-defined, vessel-specific, significant CAD.

Single-nuclear transcriptome profiling identifies persistent fibroblast activation in hypertrophic and failing human hearts of patients with longstanding disease

AIMS

Cardiac fibrosis drives the progression of heart failure in ischaemic and hypertrophic cardiomyopathy. Therefore, the development of specific anti-fibrotic treatment regimens to counteract cardiac fibrosis is of high clinical relevance. Hence, this study examined the presence of persistent fibroblast activation during longstanding human heart disease at a single-cell resolution to identify putative therapeutic targets to counteract pathological cardiac fibrosis in patients.

METHODS AND RESULTS

We used single-nuclei RNA sequencing with human tissues from two samples of one healthy donor, and five hypertrophic and two failing hearts. Unsupervised sub-clustering of 7110 nuclei led to the identification of 7 distinct fibroblast clusters. De-convolution of cardiac fibroblast heterogeneity revealed a distinct population of human cardiac fibroblasts with a molecular signature of persistent fibroblast activation and a transcriptional switch towards a pro-fibrotic extra-cellular matrix composition in patients with established cardiac hypertrophy and heart failure. This sub-cluster was characterized by high expression of POSTN, RUNX1, CILP, and a target gene adipocyte enhancer-binding protein 1 (AEBP1) (all P < 0.001). Strikingly, elevated circulating AEBP1 blood level were also detected in a validation cohort of patients with confirmed cardiac fibrosis and hypertrophic cardiomyopathy by cardiac magnetic resonance imaging (P < 0.01). Since endogenous AEBP1 expression was increased in patients with established cardiac hypertrophy and heart failure, we assessed the functional consequence of siRNA-mediated AEBP1 silencing in human cardiac fibroblasts. Indeed, AEBP1 silencing reduced proliferation, migration, and fibroblast contractile capacity and α-SMA gene expression, which is a hallmark of fibroblast activation (all P < 0.05). Mechanistically, the anti-fibrotic effects of AEBP1 silencing were linked to transforming growth factor-beta pathway modulation.

CONCLUSION

Together, this study identifies persistent fibroblast activation in patients with longstanding heart disease, which might be detected by circulating AEBP1 and therapeutically modulated by its targeted silencing in human cardiac fibroblasts.

Cardiac Involvement Due to COVID-19: Insights from Imaging and Histopathology

Lingering cardiac symptoms are increasingly recognised complications of severe acute respiratory syndrome coronavirus 2 infection, now referred to as post-acute cardiovascular sequelae of COVID-19 (PASC). In the acute phase, cardiac injury is driven by cytokine release and stems from ischaemic and thrombotic complications, resulting in myocardial necrosis. Patients with pre-existing cardiac conditions are particularly vulnerable. Myocarditis due to a direct viral infection is rare. Chronic symptoms relate to either worsening of pre-existing heart disease (PASC - cardiovascular disease) or delayed chronic inflammatory condition due to heterogenous immune dysregulation (PASC - cardiovascular syndrome), the latter affecting a broad segment of previously well people. Both PASC presentations are associated with increased cardiovascular risk, long-term disability and reduced quality of life. The recognition and management of PASC in clinical settings remains a considerable challenge. Sensitive diagnostic methods are needed to detect subtler inflammatory changes that underlie the persistent symptoms in PASC - cardiovascular syndrome, alongside considerable clinical experience in inflammatory cardiac conditions.

Computed tomography-based pericoronary adipose tissue attenuation in patients undergoing TAVR: a novel method for risk assessment

Objectives

This study aims to assess the attenuation of pericoronary adipose tissue (PCAT) surrounding the proximal right coronary artery (RCA) in patients with aortic stenosis (AS) and undergoing transcatheter aortic valve replacement (TAVR). RCA PCAT attenuation is a novel computed tomography (CT)-based marker for evaluating coronary inflammation. Coronary artery disease (CAD) in TAVR patients is common and usually evaluated prior to intervention. The most sensible screening method and consequential treatment approach are unclear and remain a matter of ceaseless discussion. Thus, interest remains for safe and low-demand predictive markers to identify patients at risk for adverse outcomes postaortic valve replacement.

Methods

This single-center retrospective study included patients receiving a standard planning CT scan prior to TAVR. Conventional CAD diagnostic tools, such as coronary artery calcium score and significant stenosis via invasive coronary angiography and coronary computed tomography angiography, were determined in addition to RCA PCAT attenuation using semiautomated software. These were assessed for their relationship with major adverse cardiovascular events (MACE) during a 24-month follow-up period.

Results

From a total of 62 patients (mean age: 82 ± 6.7 years), 15 (24.2%) patients experienced an event within the observation period, 10 of which were attributed to cardiovascular death. The mean RCA PCAT attenuation was higher in patients enduring MACE than that in those without an endpoint (-69.8 ± 7.5 vs. -74.6 ± 6.2, P = 0.02). Using a predefined cutoff of >-70.5 HU, 20 patients (32.3%) with high RCA PCAT attenuation were identified, nine (45%) of which met the endpoint within 2 years after TAVR. In a multivariate Cox regression model including conventional CAD diagnostic tools, RCA PCAT attenuation prevailed as the only marker with significant association with MACE (P = 0.02). After dichotomization of patients into high- and low-RCA PCAT attenuation groups, high attenuation was related to greater risk of MACE (hazard ration: 3.82, P = 0.011).

Conclusion

RCA PCAT attenuation appears to have predictive value also in a setting of concomitant AS in patients receiving TAVR. RCA PCAT attenuation was more reliable than conventional CAD diagnostic tools in identifying patients at risk for MACE .

Cardiac Imaging Biomarkers in Chronic Kidney Disease

Uremic cardiomyopathy (UC), the peculiar cardiac remodeling secondary to the systemic effects of renal dysfunction, is characterized by left ventricular (LV) diffuse fibrosis with hypertrophy (LVH) and stiffness and the development of heart failure and increased rates of cardiovascular mortality. Several imaging modalities can be used to obtain a non-invasive assessment of UC by different imaging biomarkers, which is the focus of the present review. Echocardiography has been largely employed in recent decades, especially for the determination of LVH by 2-dimensional imaging and diastolic dysfunction by pulsed-wave and tissue Doppler, where it retains a robust prognostic value; more recent techniques include parametric assessment of cardiac deformation by speckle tracking echocardiography and the use of 3D-imaging. Cardiac magnetic resonance (CMR) imaging allows a more accurate assessment of cardiac dimensions, including the right heart, and deformation by feature-tracking imaging; however, the most evident added value of CMR remains tissue characterization. T1 mapping demonstrated diffuse fibrosis in CKD patients, increasing with the worsening of renal disease and evident even in early stages of the disease, with few, but emerging, prognostic data. Some studies using T2 mapping highlighted the presence of subtle, diffuse myocardial edema. Finally, computed tomography, though rarely used to specifically assess UC, might provide incidental findings carrying prognostic relevance, including information on cardiac and vascular calcification. In summary, non-invasive cardiovascular imaging provides a wealth of imaging biomarkers for the characterization and risk-stratification of UC; integrating results from different imaging techniques can aid a better understanding of the physiopathology of UC and improve the clinical management of patients with CKD.

Cancer patients with venous thromboembolism: Diagnostic and prognostic value of elevated D-dimers

BACKGROUND

D-dimer testing is known to have a high sensitivity at simultaneously low specificity, resulting in nonspecific elevations in a variety of conditions.

METHODS

This retrospective study sought to assess diagnostic and prognostic features of D-dimers in cancer patients referred to the emergency department for suspected pulmonary embolism (PE) and deep vein thrombosis (DVT). In total, 526 patients with a final adjudicated diagnosis of PE (n = 83) and DVT (n = 69) were enrolled, whereas 374 patients served as the comparative group, in which venous thromboembolism (VTE) has been excluded.

RESULTS

For the identification of VTE, D-dimers yielded the highest positive predictive value of 96% (95% confidence interval (CI), 85-99) at concentrations of 9.9 mg/L and a negative predictive value of 100% at .6 mg/L (95% CI, 97-100). At the established rule-out cut-off level of .5 mg/L, D-dimers were found to be very sensitive (100%) at a moderate specificity of nearly 65%. Using an optimised cut-off value of 4.9 mg/L increased the specificity to 95% for the detection of life-threatening VTE at the cost of moderate sensitivities (64%). During a median follow-up of 30 months, D-dimers positively correlated with the reoccurrence of VTE (p = .0299) and mortality in both cancer patients with VTE (p < .0001) and without VTE (p = .0008).

CONCLUSIONS

Although D-dimer testing in cancer patients is discouraged by current guidelines, very high concentrations above the 10-fold upper reference limit contain diagnostic and prognostic information and might be helpful in risk assessment, while low concentrations remain useful for ruling out VTE.

Myocardial tissue changes detected by cardiac MRI in a patient with suspected systemic sarcoidosis

BACKGROUND

The role of cardiac magnetic resonance imaging in the early management of chronic cardiac inflammatory conditions is growing. Our case enlightens the benefit of quantitative mapping in the monitoring and treatment guidance in systemic sarcoidosis.

CASE PRESENTATION

We report about a 29-year-old man with an ongoing dyspnea and bihilar lymphadenopathy, suggesting sarcoidosis. Cardiac magnetic resonance showed high mapping values, but no scarring. In follow-ups, cardiac remodeling was noted; cardioprotective treatment normalized cardiac function and mapping markers. Definitive diagnosis was achieved in extracardiac lymphatic tissue during a relapse.

CONCLUSION

This case shows the role that mapping markers can play in the detection and treatment at early stage of systemic sarcoidosis.

Myocardial oedema contributes to interstitial expansion and associates with mechanical and electrocardiographic changes in takotsubo syndrome: a CMR T1 and T2 mapping study

AIMS

myocardial oedema is largely represented in takotsubo syndrome (TTS) and may contribute to alter the myocardium morphology and function. The aim of the study is to describe relationships between oedema, mechanical, and electrical abnormalities in TTS.

METHODS AND RESULTS

the study included n = 32 hospitalized TTS patients and n = 23 controls. Cardiac magnetic resonance (CMR) with tissue mapping and feature tracking was performed with concomitant 12-lead electrocardiogram (ECG) recording. Mean age of TTS was 72 ± 12 years old, 94% women. Compared with controls, patients had higher left ventricular (LV) mass, worse systolic function, higher septal native T1 (1116 ± 73 msec vs. 970 ± 23 msec, P < 0.001), T2 (56 ± 5 msec vs. 46 ± 2 msec, P < 0.001), and extracellular volume (ECV) fraction (32 ± 5% vs. 24 ± 1%, P < 0.001). TTS patients had higher apicobasal gradient of T2 values (12 ± 6 msec vs. 2 ± 6 msec, P < 0.001); basal LV wall displayed higher native T1, T2, and ECV (all P < 0.002) but similar circumferential strain against controls (-23 ± 3% vs. -24 ± 4%, P = 0.351). In the TTS cohort, septal T2 values showed significant correlations with native T1 (r = 0.609, P < 0.001), ECV (r = 0.689, P < 0.001), left ventricular ejection fraction (r = -0.459, P = 0.008) and aVR voltage (r = -0.478, P = 0.009). Negative T-wave voltage and QTc length correlated with apicobasal T2 mapping gradient (r = 0.499, P = 0.007 and r = 0.372, P = 0.047, respectively) but not with other tissue mapping measurements.

CONCLUSIONS

CMR T1 and T2 mapping demonstrated increased myocardial water content conditioning interstitial expansion in acute TTS, detected even outside areas of abnormal wall motion. Oedema burden and distribution associated with mechanical and electrocardiographic changes, making it a potential prognostic marker and therapeutic target in TTS.

Native T1 is predictive of cardiovascular death/heart failure events and all-cause mortality irrespective of the patient's volume status

Background

Native T1 has become a pivotal parameter of tissue composition that is assessed by cardiac magnetic resonance (CMR). It characterizes diseased myocardium and can be used for prognosis estimation. Recent publications have shown that native T1 is influenced by short-term fluctuations of volume status due to hydration or hemodialysis.

Methods

Patients from a prospective BioCVI all-comers clinical CMR registry were included, and native T1 and plasma volume status (PVS) were determined according to Hakim's formula as surrogate markers of patient volume status. The primary endpoint was defined as combined endpoint of cardiovascular death or hospitalization for heart failure events, the secondary endpoint was defined as all-cause mortality.

Results

A total of 2,047 patients were included since April 2017 [median (IQR); age 63 (52-72) years, 33% female]. There was a significant although weak influence of PVS on native T1 (β = 0.11, p < 0.0001). Patients with volume expansion (PVS > -13%) showed significantly higher values for tissue markers than non-volume-overloaded patients [PVS ≤ -13%; median (IQR); native T1 1,130 (1,095-1,170) vs. 1,123 (1,086-1,166) ms, p < 0.003; and T2 39 (37-40) vs. 38 (36-40) ms, p < 0.0001]. In Cox regression analysis both native T1 and PVS were independently predictive of the primary endpoint and all-cause mortality.

Conclusion

Despite a weak effect of PVS on native T1, its predictive power was not affected in a large, all-comers cohort.

Accuracy of stress perfusion cardiac magnetic resonance imaging in a district hospital

Background

The European Society of Cardiology has published updated guidelines regarding pathways for diagnosis and management of obstructive coronary artery disease (CAD). Non-invasive functional assessment, for example, by stress perfusion cardiac magnetic resonance (stress pCMR) is recommended in patients with intermediate pretest probability of disease. Previous pCMR studies were mainly performed in high volume university hospitals with experienced radiologists or cardiologists interpreting the images.

Purpose

The aim of the present study was to evaluate the feasibility of establishing a stress pCMR imaging service in a district hospital.

Material and Methods

One hundred and thirteen patients with intermediate pretest probability of CAD referred for single-photon emission computed tomography (SPECT) at the regional hospital also underwent adenosine stress pCMR locally. The diagnostic analysis was compared to that of an experienced cardiac magnetic resonance (CMR) center serving as a reference.

Results

Inter-rater agreement between local readers and the reference reader was substantial to perfect for late gadolinium enhancement (LGE) (weighted kappa = 0.76 and 0.82), but only fair to moderate for pCMR (k = 0.34 and 0.51). No improvement in agreement between reference reader and local reader during the study was demonstrated.

Conclusion

CMR is feasible in patients with intermediate pretest probability of obstructive CAD in the setting of a district hospital. However, as opposed to infarct detection with LGE, the interpretation of stress pCMR was more challenging. To establish this method, we suggest obtaining experience in close collaboration with a reference CMR center.

Multimodality Imaging in HIV-Associated Cardiovascular Complications: A Comprehensive Review

Human immunodeficiency virus (HIV) infection is a leading cause of mortality and morbidity worldwide. The introduction of antiretroviral therapy (ART) has significantly reduced the risk of developing acquired immune deficiency syndrome and increased life expectancy, approaching that of the general population. However, people living with HIV have a substantially increased risk of cardiovascular diseases despite long-term viral suppression using ART. HIV-associated cardiovascular complications encompass a broad spectrum of diseases that involve the myocardium, pericardium, coronary arteries, valves, and systemic and pulmonary vasculature. Traditional risk stratification tools do not accurately predict cardiovascular risk in this population. Multimodality imaging plays an essential role in the evaluation of various HIV-related cardiovascular complications. Here, we emphasize the role of multimodality imaging in establishing the diagnosis and aetiopathogenesis of various cardiovascular manifestations related to chronic HIV disease. This review also provides a critical appraisal of contemporary data and illustrative cases.

The Future of Cardiac Magnetic Resonance Clinical Trials

Over the past 2 decades, cardiac magnetic resonance (CMR) has become an essential component of cardiovascular clinical care and contributed to imaging-guided diagnosis and management of coronary artery disease, cardiomyopathy, congenital heart disease, cardio-oncology, valvular, and vascular disease, amongst others. The widespread availability, safety, and capability of CMR to provide corresponding anatomical, physiological, and functional data in 1 imaging session can improve the design and conduct of clinical trials through both a reduction of sample size and provision of important mechanistic data that may augment clinical trial findings. Moreover, prospective imaging-guided strategies using CMR can enhance safety, efficacy, and cost-effectiveness of cardiovascular pathways in clinical practice around the world. As the future of large-scale clinical trial design evolves to integrate personalized medicine, cost-effectiveness, and mechanistic insights of novel therapies, the integration of CMR will continue to play a critical role. In this document, the attributes, limitations, and challenges of CMR's integration into the future design and conduct of clinical trials will also be covered, and recommendations for trialists will be explored. Several prominent examples of clinical trials that test the efficacy of CMR-imaging guided pathways will also be discussed.

QFR vs. perfusion imaging to predict abnormal FFR in patients with prior coronary artery disease

Background

In patients with suspected obstructive coronary artery disease (CAD) and a high pre-test probability, myocardial perfusion imaging (MPI) or referral for invasive coronary angiography (ICA) are viable diagnostic strategies. The present study compared the diagnostic performance of quantitative flow ratio (QFR) and MPI by single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (CMR).

Methods

In this PACIFIC-II substudy, 189 patients with prior MI/PCI who were suspected of having symptoms related to myocardial ischemia and underwent SPECT, PET, and CMR before ICA were evaluated for inclusion. ICA was obtained with (109 patients) and without (80 patients) adherence to a QFR acquisition protocol. All major coronary arteries were interrogated by FFR, except for vessels with a subtotal/total occlusion. An FFR ≤0.80 was used to define significant epicardial CAD. QFR analyses (v2.0) were performed based on ICA by a corelab in vascular territories (N=487) in which FFR was obtained. MPI modalities were assessed for presence of ischemia by corelabs, uninterpretable scans were omitted from the diagnostic comparison analyses.

Results

QFR analysis success rate was higher (81%) among vessels acquired using the QFR acquisition protocol compared to vessels obtained without the protocol (52%, p&lt;0.001). Overall, a QFR result was available in 334 (69%) vessels. Among these vessels, QFR had a higher sensitivity (72%) and accuracy (84%) compared to SPECT (46%, p=0.001 and 66%, p&lt;0.001), PET (58%, p=0.032 and 65%, p&lt;0.001), and CMR (33%, p&lt;0.001 and 72%, p&lt;0.001). Whereas specificity of QFR (87%) was similar to CMR (83%, p=0.123) but higher than that of SPECT (71%, p&lt;0.001) and PET (67%, p&lt;0.001). Lastly, QFR exhibited a higher area under the receiver operating characteristic curve (0.89) than SPECT (0.57, p&lt;0.001), PET (0.66, p&lt;0.001), and CMR (0.60, p&lt;0.001).

Conclusions

Provided QFR was analyzable (69% of the vessels), QFR correlated better with FFR (both as measures of epicardial CAD) than MPI as reflected in the diagnostic performance measures for detecting vessels-specific significant epicardial CAD as defined by FFR.

Funding Acknowledgement

Type of funding sources: None.

Long-term cardiac pathology in individuals with mild initial COVID-19 illness

Cardiac symptoms are increasingly recognized as late complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in previously well individuals with mild initial illness, but the underlying pathophysiology leading to long-term cardiac symptoms remains unclear. In this study, we conducted serial cardiac assessments in a selected population of individuals with Coronavirus Disease 2019 (COVID-19) with no previous cardiac disease or notable comorbidities by measuring blood biomarkers of heart injury or dysfunction and by performing magnetic resonance imaging. Baseline measurements from 346 individuals with COVID-19 (52% females) were obtained at a median of 109 days (interquartile range (IQR), 77-177 days) after infection, when 73% of participants reported cardiac symptoms, such as exertional dyspnea (62%), palpitations (28%), atypical chest pain (27%) and syncope (3%). Symptomatic individuals had higher heart rates and higher imaging values or contrast agent accumulation, denoting inflammatory cardiac involvement, compared to asymptomatic individuals. Structural heart disease or high levels of biomarkers of cardiac injury or dysfunction were rare in symptomatic individuals. At follow-up (329 days (IQR, 274-383 days) after infection), 57% of participants had persistent cardiac symptoms. Diffuse myocardial edema was more pronounced in participants who remained symptomatic at follow-up as compared to those who improved. Female gender and diffuse myocardial involvement on baseline imaging independently predicted the presence of cardiac symptoms at follow-up. Ongoing inflammatory cardiac involvement may, at least in part, explain the lingering cardiac symptoms in previously well individuals with mild initial COVID-19 illness.

The German National Pandemic Cohort Network (NAPKON): rationale, study design and baseline characteristics

The German government initiated the Network University Medicine (NUM) in early 2020 to improve national research activities on the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic. To this end, 36 German Academic Medical Centers started to collaborate on 13 projects, with the largest being the National Pandemic Cohort Network (NAPKON). The NAPKON’s goal is creating the most comprehensive Coronavirus Disease 2019 (COVID-19) cohort in Germany. Within NAPKON, adult and pediatric patients are observed in three complementary cohort platforms (Cross-Sectoral, High-Resolution and Population-Based) from the initial infection until up to three years of follow-up. Study procedures comprise comprehensive clinical and imaging diagnostics, quality-of-life assessment, patient-reported outcomes and biosampling. The three cohort platforms build on four infrastructure core units (Interaction, Biosampling, Epidemiology, and Integration) and collaborations with NUM projects. Key components of the data capture, regulatory, and data privacy are based on the German Centre for Cardiovascular Research. By April 01, 2022, 34 university and 40 non-university hospitals have enrolled 5298 patients with local data quality reviews performed on 4727 (89%). 47% were female, the median age was 52 (IQR 36–62-) and 50 pediatric cases were included. 44% of patients were hospitalized, 15% admitted to an intensive care unit, and 12% of patients deceased while enrolled. 8845 visits with biosampling in 4349 patients were conducted by April 03, 2022. In this overview article, we summarize NAPKON’s design, relevant milestones including first study population characteristics, and outline the potential of NAPKON for German and international research activities.

Trial registrationhttps://clinicaltrials.gov/ct2/show/NCT04768998.https://clinicaltrials.gov/ct2/show/NCT04747366.https://clinicaltrials.gov/ct2/show/NCT04679584

Functional stress imaging to predict abnormal coronary fractional flow reserve: the PACIFIC 2 study

AIMS

The diagnostic performance of non-invasive imaging in patients with prior coronary artery disease (CAD) has not been tested in prospective head-to-head comparative studies. The aim of this study was to compare the diagnostic performance of qualitative single-photon emission computed tomography (SPECT), quantitative positron emission tomography (PET), and qualitative magnetic resonance imaging (MRI) in patients with a prior myocardial infarction (MI) or percutaneous coronary intervention (PCI).

METHODS AND RESULTS

In this prospective clinical study, all patients with prior MI and/or PCI and new symptoms of ischaemic CAD underwent 99mTc-tetrofosmin SPECT, [15O]H2O PET, and MRI, followed by invasive coronary angiography with fractional flow reserve (FFR) in all coronary arteries. All modalities were interpreted by core laboratories. Haemodynamically significant CAD was defined by at least one coronary artery with an FFR ≤0.80. Among the 189 enrolled patients, 63% had significant CAD. Sensitivity was 67% (95% confidence interval 58-76%) for SPECT, 81% (72-87%) for PET, and 66% (56-75%) for MRI. Specificity was 61% (48-72%) for SPECT, 65% (53-76%) for PET, and 62% (49-74%) for MRI. Sensitivity of PET was higher than SPECT (P = 0.016) and MRI (P = 0.014), whereas specificity did not differ among the modalities. Diagnostic accuracy for PET (75%, 68-81%) did not statistically differ from SPECT (65%, 58-72%, P = 0.03) and MRI (64%, 57-72%, P = 0.052). Using FFR < 0.75 as a reference, accuracies increased to 69% (SPECT), 79% (PET), and 71% (MRI).

CONCLUSION

In this prospective head-to-head comparative study, SPECT, PET, and MRI did not show a significantly different accuracy for diagnosing FFR defined significant CAD in patients with prior PCI and/or MI. Overall diagnostic performances, however, were discouraging and the additive value of non-invasive imaging in this high-risk population is questionable.

Cardiovascular Magnetic Resonance for Patients With COVID-19

COVID-19 is associated with myocardial injury caused by ischemia, inflammation, or myocarditis. Cardiovascular magnetic resonance (CMR) is the noninvasive reference standard for cardiac function, structure, and tissue composition. CMR is a potentially valuable diagnostic tool in patients with COVID-19 presenting with myocardial injury and evidence of cardiac dysfunction. Although COVID-19-related myocarditis is likely infrequent, COVID-19-related cardiovascular histopathology findings have been reported in up to 48% of patients, raising the concern for long-term myocardial injury. Studies to date report CMR abnormalities in 26% to 60% of hospitalized patients who have recovered from COVID-19, including functional impairment, myocardial tissue abnormalities, late gadolinium enhancement, or pericardial abnormalities. In athletes post-COVID-19, CMR has detected myocarditis-like abnormalities. In children, multisystem inflammatory syndrome may occur 2 to 6 weeks after infection; associated myocarditis and coronary artery aneurysms are evaluable by CMR. At this time, our understanding of COVID-19-related cardiovascular involvement is incomplete, and multiple studies are planned to evaluate patients with COVID-19 using CMR. In this review, we summarize existing studies of CMR for patients with COVID-19 and present ongoing research. We also provide recommendations for clinical use of CMR for patients with acute symptoms or who are recovering from COVID-19.

[Surgery in the balance between humanity, ethics and economics]

BACKGROUND

The economic pressure in the healthcare system has noticeably increased in the past few years. The manifestation of an "economization in medicine" development raises questions about the compatibility of physicians' duties and economic incentives in the healthcare system.

OBJECTIVE

Against this background the article analyzes areas of conflict in the German healthcare system and surgery in particular. The main questions focus on: what lines of conflict can arise between ethical duties and economic requirements and what possibilities for conflict resolution can provide orientation on the macrolevel and microlevel?

MATERIAL AND METHODS

The article is based on the analysis of normative regulations, guidelines and statements from the self-administrative institutions and multidisciplinary literature from medicine, medical ethics and health economics. Core issues in the conflict area between "humanity-ethics-economics" are structured and recommendations for action are derived.

RESULTS AND DISCUSSION

Superordinate regulatory framework conditions and their subsequent incentives must not conflict with the ethical principles of medical care, especially the primary orientation to patient welfare. Institutional and individual healthcare providers have a responsibility towards patients first and only secondarily for an economically appropriate spending of public resources. The provision of medical care for people must enable an adequate livelihood. Institutional maximization of profits is to be avoided, especially concerning financial investors. In the corona pandemic, economic disincentives are becoming apparent and necessitate readjustments. Possible recommendations for action are the empowerment of the medical profession and management to engage in a qualified exchange.

Myocardial viability testing: all STICHed up, or about to be REVIVED?

Patients with ischaemic left ventricular dysfunction frequently undergo myocardial viability testing. The historical model presumes that those who have extensive areas of dysfunctional-yet-viable myocardium derive particular benefit from revascularization, whilst those without extensive viability do not. These suppositions rely on the theory of hibernation and are based on data of low quality: taking a dogmatic approach may therefore lead to patients being refused appropriate, prognostically important treatment. Recent data from a sub-study of the randomized STICH trial challenges these historical concepts, as the volume of viable myocardium failed to predict the effectiveness of coronary artery bypass grafting. Should the Heart Team now abandon viability testing, or are new paradigms needed in the way we interpret viability? This state-of-the-art review critically examines the evidence base for viability testing, focusing in particular on the presumed interactions between viability, functional recovery, revascularization and prognosis which underly the traditional model. We consider whether viability should relate solely to dysfunctional myocardium or be considered more broadly and explore wider uses of viability testingoutside of revascularization decision-making. Finally, we look forward to ongoing and future randomized trials, which will shape evidence-based clinical practice in the future.

Evidence-based cardiovascular magnetic resonance cost-effectiveness calculator for the detection of significant coronary artery disease

BACKGROUND

Although prior reports have evaluated the clinical and cost impacts of cardiovascular magnetic resonance (CMR) for low-to-intermediate-risk patients with suspected significant coronary artery disease (CAD), the cost-effectiveness of CMR compared to relevant comparators remains poorly understood. We aimed to summarize the cost-effectiveness literature on CMR for CAD and create a cost-effectiveness calculator, useable worldwide, to approximate the cost-per-quality-adjusted-life-year (QALY) of CMR and relevant comparators with context-specific patient-level and system-level inputs.

METHODS

We searched the Tufts Cost-Effectiveness Analysis Registry and PubMed for cost-per-QALY or cost-per-life-year-saved studies of CMR to detect significant CAD. We also developed a linear regression meta-model (CMR Cost-Effectiveness Calculator) based on a larger CMR cost-effectiveness simulation model that can approximate CMR lifetime discount cost, QALY, and cost effectiveness compared to relevant comparators [such as single-photon emission computed tomography (SPECT), coronary computed tomography angiography (CCTA)] or invasive coronary angiography.

RESULTS

CMR was cost-effective for evaluation of significant CAD (either health-improving and cost saving or having a cost-per-QALY or cost-per-life-year result lower than the cost-effectiveness threshold) versus its relevant comparator in 10 out of 15 studies, with 3 studies reporting uncertain cost effectiveness, and 2 studies showing CCTA was optimal. Our cost-effectiveness calculator showed that CCTA was not cost-effective in the US compared to CMR when the most recent publications on imaging performance were included in the model.

CONCLUSIONS

Based on current world-wide evidence in the literature, CMR usually represents a cost-effective option compared to relevant comparators to assess for significant CAD.

Patterns of cardiac involvement in patients with long COVID syndrome using cardiovascular magnetic resonance

Background

Long COVID (LC) is an increasingly recognized late complication of COVID-19 infection. Cardiovascular involvement has also been implicated, however, the type and extent of the underlying cardiovascular injury remains unknown.

Purpose

To evaluate the association between ongoing symptoms and findings with cardiovascular magnetic resonance (CMR) in consecutive patients recently recovered from COVID-19 illness.

Methods

Prospective observational cohort study of patients recently recovered from COVID-19 illness and no previously known cardiovascular disease were included between April 2020 and April 2021. Demographic characteristics, cardiac blood markers, and CMR imaging a minimum of 4 weeks from the diagnosis were obtained.

Results

Of the 389 included patients, 192 (49%) were male, the mean (±standard deviation) age was 44 (±13) years and 61 (16%) required hospitalization during the acute illness. The median (IQR) time interval between COVID-19 diagnosis and CMR was 94 (71–165) days. 298 (77%) of patients continued to experience ongoing cardiovascular symptoms (long COVID, LC), including dyspnea, palpitations, atypical chest pain and fatigue at the time of CMR at least 4 weeks after the infection. In most patients, the symptoms were only effort related 137 (46%), whereas in 98 (33%) the symptoms affected the activities of daily life; 10 (3%) had severe and debilitating symptoms at rest. Compared to those with no LC (NLC, n=91), LC patients were more commonly hospitalized, had significantly higher native T1, native T2, and showed pericardial enhancement and effusion (Figure 1). There were no differences in cardiac biomarkers, left ventricular (LV) and right ventricular ejection fraction and mass. Proportionally, men and women were similarly affected (n=144 (73%) vs. n=157 (80%), p=0.18). Previous hospitalization was associated with hypertension and ongoing detectable troponin. LC status was associated with previous hospitalization and CMR findings of raised native T1 and native T2, and in females also pericardial enhancement. Severity of symptoms were associated with increased native T1 and T2 and decreased end-diastolic volume, whereas cardiac function showed no significant difference.

Conclusions

In this cohort of patients recently recovered from COVID-19 infection, ongoing cardiovascular symptoms were common. The LC status was related to previous hospitalization and CMR imaging findings of myopericardial inflammation. The extent and type of cardiovascular findings was associated with the severity of symptoms. These findings indicate the need for ongoing investigation of the long-term cardiovascular consequences of COVID-19.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The German Heart Foundation (Deutsche Herzstiftung) and Bayer AG, Leverkusen, Germany

Clinical risk score for individualized risk stratification of patients with clinically suspected myocardial inflammation

Objective

To develop a clinical risk score for individualized risk stratification of patients with clinically suspected myocardial inflammation.

Background

Myocardial inflammation is a prominent cause of non-ischaemic dilated cardiomyopathy, heart failure (HF) and sudden cardiac death.

Methods

This is a prospective multicentre longitudinal study of consecutive patients referred to cardiac magnetic resonance (CMR) with clinically suspected myocardial inflammation between October 2011 and December 2019 as a part of standard diagnostic pathway. Patients were followed up from the date of CMR. The outcome endpoints included major adverse cardiovascular event (MACE, cardiovascular mortality, sudden cardiac death, appropriate device discharge); or death or hospitalisation due to HF). A prognostic model was developed using Cox proportional hazards analysis and validated internally and externally.

Results

The final dataset included 722 subjects (50 years (40–61); males 422 (58%)). During a follow-up period of median 19 (15–23) months, there were 64 (9%) MACE and 130 (18%) HF events. Ten predictor variables qualified for entry into the prognostic model: age, sex, hematocrit, C-reactive protein, high-sensitive troponin-T (TNT), left and right ventricular ejection fraction, native T1 and T2, and late gadolinium enhancement (LGE). The final multivariable Cox regression model included native T2 (Figure 1A), TNT and LGE (Figure 1B) for the primary (Chi-square: 102.0, p&lt;0.001) and secondary endpoint (Chi-square: 166.9, p&lt;0.001), respectively. Cross-validation as well as external validation of the secondary models revealed good performance and no healthcare system effect. Based on the MyoRISK Score, patients were classified into three risk groups with respective event rates for MACE of 0%, 6.3% and 25.1%, and HF endpoint of 1.8%, 17.3% and 44.2%. TNT≥7 pg/ml allowed to efficiently preselect patients prior to CMR.

Conclusions

This is the first systematic assessment of outcomes in patients with clinically suspected myocardial inflammation, providing a non-invasive estimation of the probability of adverse events based on a score using readily available clinical parameters.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): DZHK

Non-invasive CMR-Based Quantification of Myocardial Power and Efficiency Under Stress and Ischemic Conditions in Landrace Pigs

Background: Myocardial efficiency should be maintained stable under light-to-moderate stress conditions, but ischemia puts the myocardium at risk for impaired functionality. Additionally, the measurement of such efficiency typically requires invasive heart catheterization and exposure to ionizing radiation. In this work, we aimed to non-invasively assess myocardial power and the resulting efficiency during pharmacological stress testing and ischemia induction. Methods: In a cohort of n = 10 healthy Landrace pigs, dobutamine stress testing was performed, followed by verapamil-induced ischemia alongside cardiac magnetic resonance (CMR) imaging. External myocardial power, internal myocardial power, and myocardial efficiency were assessed non-invasively using geometrical and functional parameters from CMR volumetric as well as blood flow and pressure measurements. Results: External myocardial power significantly increased under dobutamine stress [2.3 (1.6-3.1) W/m² vs. 1.3 (1.1-1.6) W/m², p = 0.005] and significantly decreased under verapamil-induced ischemia [0.8 (0.5-0.9) W/m², p = 0.005]. Internal myocardial power [baseline: 5.9 (4.6-8.5) W/m²] was not affected by dobutamine [7.5 (6.9-9.0) W/m², p = 0.241] nor verapamil [5.8 (4.7-8.8) W/m², p = 0.878]. Myocardial efficiency did not change from baseline to dobutamine [21% (15-27) vs. 31% (20-44), p = 0.059] but decreased significantly during verapamil-induced ischemia [10% (8-13), p = 0.005]. Conclusion: In healthy Landrace pigs, dobutamine stress increased external myocardial power, whereas myocardial efficiency was maintained stable. On the contrary, verapamil-induced ischemia substantially decreased external myocardial power and myocardial efficiency. Non-invasive CMR was able to quantify these efficiency losses and might be useful for future clinical studies evaluating the effects of therapeutic interventions on myocardial energetics.

Outcomes of cardiovascular magnetic resonance imaging in people living with HIV

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

People living with human immunodeficiency virus (HIV, PLWH) are at increased risk of cardiovascular disease (CVD). HIV infection and accelerated traditional risk factors due to highly-active antiretroviral therapy (HAART) are proposed mechanisms for increased rate of heart failure (HF). The pathophysiological drivers of myocardial dysfunction and worse cardiovascular outcome in HIV remain poorly understood.

Purpose

To examine prognostic relationships of cardiac imaging measures with cardiovascular outcome in PLWH on HAART.

Methods

This is a prospective observational longitudinal study using cardiac magnetic resonance (CMR) imaging in consecutive PLHWH on long-term HAART who were screened for underlying CVD and followed up clinically for adjudicated adverse cardiovascular events (cardiovascular mortality, non-fatal acute coronary syndrome, an appropriate device discharge, or a documented HF hospitalization). Imaging protocol included routine assessment of cardiac volumes and function, scar by late gadolinium enhancement, myocardial perfusion and native T1 /T2 mapping. Time-to-event analysis was performed from the index CMR exam to the first single event per patient Systematic risk scores for CVD (Framingham risk score (FRS), Data Collection on Adverse effects of anti-HIV Drugs score, D:A:D and MAGGIC integer score) were calculated using original online calculators.

Results

156 participants (males 62%, 50 [42-57] years of age) were included. 24 events were observed (4 HF deaths, 1 sudden cardiac death, 2 non-fatal acute myocardial infarction, 1 appropriate device discharge and 16 HF hospitalizations) during a median follow-up of 13 [9-19] months. Patients with events had higher native T1 (ms, 1149 [1115-1163] ms vs. 1110 [1075-1138] ms), native T2 (ms, 40 [38-41] vs. 37 [36-39]), LV mass index (g/m², 65 [49-77] vs. 57 [49-64]) p &lt; 0.05 for all). In multivariable analyses, native T1 was independently predictive of adverse events (ChiSq 15.9, p &lt; 0.001, native T1 (10 ms) hazard ratio (95% confidence interval) 1.20 (1.08-1.33), p = 0.001), followed by a model that also included LV mass (ChiSq 17.1, p &lt; 0.001). Traditional cardiovascular risk scores were not predictive of the adverse events.

Conclusions

Native myocardial T1 and LV mass by CMR, as opposed to traditional cardiovascular risk scores, predict cardiovascular outcome in PLWH, together reflecting the pathological myocardial remodeling of myocardial fibrosis and inflammation that potentially explain higher rates of HF in PLWH as compared to the non-infected population. These findings may inform personalized approaches to screening and early intervention to reduce the burden of HF.

Cardiac biomarkers in chronic kidney disease are independently associated with myocardial edema and diffuse fibrosis by cardiovascular magnetic resonance

BACKGROUND

High sensitivity cardiac troponin T (hs-cTnT) and NT-pro-brain natriuretic peptide (NT-pro BNP) are often elevated in chronic kidney disease (CKD) and associated with both cardiovascular remodeling and outcome. Relationship between these biomarkers and quantitative imaging measures of myocardial fibrosis and edema by T1 and T2 mapping remains unknown.

METHODS

Consecutive patients with established CKD and estimated glomerular filtration rate (eGFR) < 59 ml/min/1.73 m2 (n = 276) were compared to age/sex matched patients with eGFR ≥ 60 ml/min/1.73 m2 (n = 242) and healthy controls (n = 38). Comprehensive cardiovascular magnetic resonance (CMR) with native T1 and T2 mapping, myocardial ischemia and scar imaging was performed with venous sampling immediately prior to CMR.

RESULTS

Patients with CKD showed significant cardiac remodeling in comparison with both healthy individuals and non-CKD patients, including a stepwise increase of native T1 and T2 (p < 0.001 between all CKD stages). Native T1 and T2 were the sole imaging markers independently associated with worsening CKD in patients [B = 0.125 (95% CI 0.022-0.235) and B = 0.272 (95% CI 0.164-0.374) with p = 0.019 and < 0.001 respectively]. At univariable analysis, both hs-cTnT and NT-pro BNP significantly correlated with native T1 and T2 in groups with eGFR 30-59 ml/min/1.73 m2 and eGFR < 29 ml/min/1.73 m2 groups, with associations being stronger at lower eGFR (NT-pro BNP (log transformed, lg10): native T1 r = 0.43 and r = 0.57, native T2 r = 0.39 and r = 0.48 respectively; log-transformed hs-cTnT(lg10): native T1 r = 0.23 and r = 0.43, native T2 r = 0.38 and r = 0.58 respectively, p < 0.001 for all, p < 0.05 for interaction). On multivariable analyses, we found independent associations of native T1 with NT-pro BNP [(B = 0.308 (95% CI 0.129-0.407), p < 0.001 and B = 0.334 (95% CI 0.154-0.660), p = 0.002 for eGFR 30-59 ml/min/1.73 m2 and eGFR < 29 ml/min/1.73 m2, respectively] and of T2 with hs-cTnT [B = 0.417 (95% CI 0.219-0.650), p < 0.001 for eGFR < 29 ml/min/1.73 m2].

CONCLUSIONS

We demonstrate independent associations between cardiac biomarkers with imaging markers of interstitial expansion, which are CKD-group specific. Our findings indicate the role of diffuse non-ischemic tissue processes, including excess of myocardial fluid in addition to diffuse fibrosis in CKD-related adverse remodeling.

Prevalence and prognostic impact of nonischemic late gadolinium enhancement in stress cardiac magnetic resonance

AIM

To assess the prevalence and prognostic significance of NI-LGE in patients undergoing stress-CMR.

METHODS

Stress-CMR with either dipyridamole or adenosine was performed in 283 patients (228 men, 81%) including perfusion imaging, wall motion evaluation and LGE. Follow-up was completed in all enrolled patients (median time: 1850 days; interquartile range: 1225-2705 days). Composite endpoint included cardiac death, ventricular tachycardia, myocardial infarction, stroke, hospitalization for cardiac cause and coronary revascularization performed beyond 90 days from stress-CMR scans.

RESULTS

One hundred and twelve patients (40%) had negative LGE (no-LGE), 140 patients (49%) I-LGE and 31 patients (11%) NI-LGE. Twenty-five events occurred in the no-LGE group, 68 in I-LGE and 11 in the NI-LGE group. On survival curves, patients with NI-LGE had worse prognosis than patients with no-LGE regardless of the presence of inducible perfusion defects. No significant prognostic differences were found between I-LGE and NI-LGE.

CONCLUSION

NI-LGE can be detected in 11% of patients during stress-CMR providing a diagnosis of nonischemic cardiac disease. Patients with NI-LGE have worse prognosis than those with no-LGE.

Development, validation, and implementation of biomarker testing in cardiovascular medicine state-of-the-art: proceedings of the European Society of Cardiology-Cardiovascular Round Table

Many biomarkers that could be used to assess ejection fraction, heart failure, or myocardial infarction fail to translate into clinical practice because they lack essential performance characteristics or fail to meet regulatory standards for approval. Despite their potential, new technologies have added to the complexities of successful translation into clinical practice. Biomarker discovery and implementation require a standardized approach that includes: identification of a clinical need; identification of a valid surrogate biomarker; stepwise assay refinement, demonstration of superiority over current standard-of-care; development and understanding of a clinical pathway; and demonstration of real-world performance. Successful biomarkers should improve efficacy or safety of treatment, while being practical at a realistic cost. Everyone involved in cardiovascular healthcare, including researchers, clinicians, and industry partners, are important stakeholders in facilitating the development and implementation of biomarkers. This article provides suggestions for a development pathway for new biomarkers, discusses regulatory issues and challenges, and suggestions for accelerating the pathway to improve patient outcomes. Real-life examples of successful biomarkers-high-sensitivity cardiac troponin, T2* cardiovascular magnetic resonance imaging, and echocardiography-are used to illustrate the value of a standardized development pathway in the translation of concepts into routine clinical practice.

Myocardial Fibrosis and Inflammation by CMR Predict Cardiovascular Outcome in People Living With HIV

OBJECTIVES

The goal of this study was to examine prognostic relationships between cardiac imaging measures and cardiovascular outcome in people living with human immunodeficiency virus (HIV) (PLWH) on highly active antiretroviral therapy (HAART).

BACKGROUND

PLWH have a higher prevalence of cardiovascular disease and heart failure (HF) compared with the noninfected population. The pathophysiological drivers of myocardial dysfunction and worse cardiovascular outcome in HIV remain poorly understood.

METHODS

This prospective observational longitudinal study included consecutive PLWH on long-term HAART undergoing cardiac magnetic resonance (CMR) examination for assessment of myocardial volumes and function, T1 and T2 mapping, perfusion, and scar. Time-to-event analysis was performed from the index CMR examination to the first single event per patient. The primary endpoint was an adjudicated adverse cardiovascular event (cardiovascular mortality, nonfatal acute coronary syndrome, an appropriate device discharge, or a documented HF hospitalization).

RESULTS

A total of 156 participants (62% male; age [median, interquartile range]: 50 years [42 to 57 years]) were included. During a median follow-up of 13 months (9 to 19 months), 24 events were observed (4 HF deaths, 1 sudden cardiac death, 2 nonfatal acute myocardial infarction, 1 appropriate device discharge, and 16 HF hospitalizations). Patients with events had higher native T1 (median [interquartile range]: 1,149 ms [1,115 to 1,163 ms] vs. 1,110 ms [1,075 to 1,138 ms]); native T2 (40 ms [38 to 41 ms] vs. 37 ms [36 to 39 ms]); left ventricular (LV) mass index (65 g/m² [49 to 77 g/m²] vs. 57 g/m² [49 to 64 g/m²]), and N-terminal pro-B-type natriuretic peptide (109 pg/l [25 to 337 pg/l] vs. 48 pg/l [23 to 82 pg/l]) (all p < 0.05). In multivariable analyses, native T1 was independently predictive of adverse events (chi-square test, 15.9; p < 0.001; native T1 [10 ms] hazard ratio [95% confidence interval]: 1.20 [1.08 to 1.33]; p = 0.001), followed by a model that also included LV mass (chi-square test, 17.1; p < 0.001). Traditional cardiovascular risk scores were not predictive of the adverse events.

CONCLUSIONS

Our findings reveal important prognostic associations of diffuse myocardial fibrosis and LV remodeling in PLWH. These results may support development of personalized approaches to screening and early intervention to reduce the burden of HF in PLWH (International T1 Multicenter Outcome Study; NCT03749343).

Myocardial T1-mapping and extracellular volume in pulmonary arterial hypertension: A systematic review and meta-analysis

INTRODUCTION

Elevated myocardial T₁-mapping and extracellular volume (ECV) measured on cardiac MR (CMR) imaging is associated with myocardial abnormalities such as oedema or fibrosis. This meta-analysis aims to provide a summary of T₁-mapping and ECV values in pulmonary arterial hypertension (PAH) and compare their values with controls.

METHODS

We searched CENTRAL, MEDLINE, Embase, and Web of Science in August 2020. We included CMR studies reporting T₁-mapping or ECV values in adults with any type of PAH. We calculated the mean difference of T₁-values and ECV between PAH and controls.

RESULTS

We included 12 studies with 674 participants. T₁-values were significantly higher in PAH with the highest mean difference (MD) recorded at the RV insertion points (RVIP) (108 milliseconds (ms), 95% confidence intervals (CI) 89 to 128), followed by the RV free wall (MD 91 ms, 95% CI 56 to 126). The pooled mean T₁-value in PAH at the RVIP was 1084, 95% CI (1071 to 1097) measured using 1.5 Tesla Siemens systems. ECV was also higher in PAH with an MD of 7.5%, 95% CI (5.9 to 9.1) at the RV free wall.

CONCLUSION

T₁ mapping values in PAH patients are on average 9% higher than healthy controls when assessed under the same conditions including the same MRI system, magnetic field strength or sequence used for acquisition. The highest T₁ and ECV values are at the RVIP. T₁ mapping and ECV values in PH are higher than the values reported in cardiomyopathies and were associated with poor RV function and RV dilatation.

Quantitative perfusion-CMR is significantly influenced by the placement of the arterial input function

The aim of this study is to provide a systematic assessment of the influence of the position on the arterial input function (AIF) for perfusion quantification. In 39 patients with a wide range of left ventricular function the AIF was determined using a diluted contrast bolus of a cardiac magnetic resonance imaging in three left ventricular levels (basal, mid, apex) as well as aortic sinus (AoS). Time to peak signal intensities, baseline corrected peak signal intensity and upslopes were determined and compared to those obtained in the AoS. The error induced by sampling the AIF in a position different to the AoS was determined by Fermi deconvolution. The time to peak signal intensity was strongly correlated (r2 > 0.9) for all positions with a systematic earlier arrival in the basal (- 2153 ± 818 ms), the mid (- 1429 ± 928 ms) and the apical slice (- 450 ± 739 ms) relative to the AoS (all p < 0.001). Peak signal intensity as well as upslopes were strongly correlated (r2 > 0.9 for both) for all positions with a systematic overestimation in all positions relative to the AoS (all p < 0.001 and all p < 0.05). Differences between the positions were more pronounced for patients with reduced ejection fraction. The error of averaged MBF quantification was 8%, 13% and 27% for the base, mid and apex. The location of the AIF significantly influences core parameters for perfusion quantification with a systematic and ejection fraction dependent error. Full quantification should be based on obtaining the AIF as close as possible to the myocardium to minimize these errors.

Determination of scar area using native and post contrast T1 mapping: a validation study

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Goethe University Hospital

Introduction

Late gadolinium enhancement (LGE) with Full Width Half Maximum (FWHM) is the standard imaging method for the measurement of the scar area in ischemic heart disease, a major determinant of adverse outcome. T1 mapping techniques have become increasingly applied in everyday clinical practice. Agreement in area quantification between T1 mapping and LGE for the scar extent has not been systematically assessed.

Purpose

This study aims to ascertain concordance between the area determined by native and post contrast T1 mapping against LGE to determine scar area in patients with a prior myocardial infarction. It also examines intra and inter-observer reproducibility for these two methods.

Methods

Subendocardial scar was evaluated in 132 patients with ischemic heart disease using LGE, native and post contrast T1 mapping in 3 short axis slices. Native and postcontrast T1 mapping was performed using GoetheCVI®MOLLI sequence (Gadovist® 0.1mmol/kg). FWHM method was applied for LGE and compared with the manually delineated area of scar in native and postcontrast T1 mapping acquisitions within the identical slices. The presence of the scar was defined as LGE &gt;3% of the myocardial mass. Bland-Altman methods were employed to assess concordance between techniques and reproducibly between observers.

Results

In comparison to LGE, area measurements in native T1 acquisitions underestimated infarct size (9,1% vs 12,6%, p = 0.01), while postcontrast T1 overestimated it (19,4% vs 12,6%, p &lt; 0.001). The disparity between the measurements was accentuated with larger scar areas (Figure 1). Intraobserver reproducibility (native T1: intra/inter MD ± SD, CoV, postcontrast T1: intra/inter) was similar with both methods, whereas interobserver variability for native T1 mapping acquisition was worse.

Conclusions

We demonstrate that measurements of the area of myocardial scar by T1 mapping acquisitions yield considerably different results in comparison to the standard LGE-based FWHM method. High observer agreement indicates that these differences are genuinely related to the type of the underlying acquisition and the differences in detected signal. The approaches are not interchangeable. However, the importance of these results for predicting patient outcome is yet to be elucidated. Nonetheless, these results were consistent in the inter and intraobserver analysis for post contrast T1 mapping, although native T1 mapping failed to show similar consistency.

Figure 1: Bland-Altmann plot of differences (mean ± upper and lower limit of agreement-LOA) in scar area extent (percentage) between LGE and native T1 mapping (A), LGE and post contrast T1 mapping (B). The difference increases linearly for larger scar areas when using post contrast mapping, which does not apply for native mapping.

Abstract Figure 1

Comparison of the T2 effects of three T1 mapping sequences of the myocardium at 3T and 1.5T

Funding Acknowledgements

Type of funding sources: None.

Purpose

To compare the T2 effects of three T1 mapping sequences of the myocardium at 3T and 1.5T. 

Materials and Methods

We measured native T1 values by three T1 mapping sequences (FFM, MPI and LONG) and T2 values of 630 consecutive subjects (patients and healthy volunteers) in a mid-ventricular short axis slice by regions of interest (ROIs) placed conservatively within the septal myocardium. Correlations between myocardial T1 and T2 values were analyzed.

Results

Native T1 values differed significantly depending on the sequence, with MPI providing consistently higher mean values than FFM and LONG, LONG providing higher mean values than FFM (all p &lt; 0.001). T1 by FFM, MPI and LONG in the total population, disease group, non-ischaemic cardiomyopathy group were all weakly related to T2 at 3T. The correlation coefficient of MPI were the highest in the total population and disease group, but there is no significant difference in correlation coefficients (all p &gt; 0.05). Similarly, T1 by FFM, LONG in the total population, disease group, NICM group were all weakly-moderately related to T2 at 1.5T. In the control group, only T1 by MPI was moderately and positively related to T2(r = 0.469, p = 0.037). In the ischaemic cardiomyopathy group, only T1 by MPI was weakly and positively related to T2 (r = 0.334, p = 0.011). In the stress condition, T1 by FFM and MPI was weakly and positively related to T2 (r = 0.280,0.210, p = 0.001,0.012, respectively).

Conclusion

The T2 effects existed in three T1 mapping sequences of the myocardium in varying degrees, we should consider the potential bias from T2 when analyzing the abnormal T1 values of myocardium.

Abstract Figure.

Diagnosis and treatment of cardiac amyloidosis: position statement of the German Cardiac Society (DGK)

Systemic forms of amyloidosis affecting the heart are mostly light-chain (AL) and transthyretin (ATTR) amyloidoses. The latter is caused by deposition of misfolded transthyretin, either in wild-type (ATTRwt) or mutant (ATTRv) conformation. For diagnostics, specific serum biomarkers and modern non-invasive imaging techniques, such as cardiovascular magnetic resonance imaging (CMR) and scintigraphic methods, are available today. These imaging techniques do not only complement conventional echocardiography, but also allow for accurate assessment of the extent of cardiac involvement, in addition to diagnosing cardiac amyloidosis. Endomyocardial biopsy still plays a major role in the histopathological diagnosis and subtyping of cardiac amyloidosis. The main objective of the diagnostic algorithm outlined in this position statement is to detect cardiac amyloidosis as reliably and early as possible, to accurately determine its extent, and to reliably identify the underlying subtype of amyloidosis, thereby enabling subsequent targeted treatment.

Left atrial strain: a multi-modality, multi-vendor comparison study

AIMS

Left atrial (LA) strain is a prognostic biomarker with utility across a spectrum of acute and chronic cardiovascular pathologies. There are limited data on intervendor differences and no data on intermodality differences for LA strain. We sought to compare the intervendor and intermodality differences between transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) derived LA strain. We hypothesized that various components of atrial strain would show good intervendor and intermodality correlation but that there would be systematic differences between vendors and modalities.

METHODS AND RESULTS

We evaluated 54 subjects (43 patients with a clinical indication for CMR and 11 healthy volunteers) in a study comparing TTE- and CMR-derived LA reservoir strain (ƐR), conduit strain (ƐCD), and contractile strain (ƐCT). The LA strain components were evaluated using four dedicated types of post-processing software. We evaluated the correlation and systematic bias between modalities and within each modality. Intervendor and intermodality correlation was: ƐR [intraclass correlation coefficient (ICC 0.64-0.90)], ƐCD (ICC 0.62-0.89), and ƐCT (ICC 0.58-0.77). There was evidence of systematic bias between vendors and modalities with mean differences ranging from (3.1-12.2%) for ƐR, ƐCD (1.6-8.6%), and ƐCT (0.3-3.6%). Reproducibility analysis revealed intraobserver coefficient of variance (COV) of 6.5-14.6% and interobserver COV of 9.9-18.7%.

CONCLUSION

Vendor derived ƐR, ƐCD, and ƐCT demonstrates modest to excellent intervendor and intermodality correlation depending on strain component examined. There are systematic differences in measurements depending on modality and vendor. These differences may be addressed by future studies, which, examine calibration of LA geometry/higher frame rate imaging, semi-quantitative approaches, and improvements in reproducibility.

Cardiovascular magnetic resonance-derived left ventricular mechanics-strain, cardiac power and end-systolic elastance under various inotropic states in swine

BACKGROUND

Cardiovascular magnetic resonance (CMR) strain imaging is an established technique to quantify myocardial deformation. However, to what extent left ventricular (LV) systolic strain, and therefore LV mechanics, reflects classical hemodynamic parameters under various inotropic states is still not completely clear. Therefore, the aim of this study was to investigate the correlation of LV global strain parameters measured via CMR feature tracking (CMR-FT, based on conventional cine balanced steady state free precession (bSSFP) images) with hemodynamic parameters such as cardiac index (CI), cardiac power output (CPO) and end-systolic elastance (Ees) under various inotropic states.

METHODS

Ten anaesthetized, healthy Landrace swine were acutely instrumented closed-chest and transported to the CMR facility for measurements. After baseline measurements, two steps were performed: (1) dobutamine-stress (Dobutamine) and (2) verapamil-induced cardiovascular depression (Verapamil). During each protocol, CMR images were acquired in the short axisand apical 2Ch, 3Ch and 4Ch views. MEDIS software was utilized to analyze global longitudinal (GLS), global circumferential (GCS), and global radial strain (GRS).

RESULTS

Dobutamine significantly increased heart rate, CI, CPO and Ees, while Verapamil decreased them. Absolute values of GLS, GCS and GRS accordingly increased during Dobutamine infusion, while GLS and GCS decreased during Verapamil. Linear regression analysis showed a moderate correlation between GLS, GCS and LV hemodynamic parameters, while GRS correlated poorly. Indexing global strain parameters for indirect measures of afterload, such as mean aortic pressure or wall stress, significantly improved these correlations, with GLS indexed for wall stress reflecting LV contractility as the clinically widespread LV ejection fraction.

CONCLUSION

GLS and GCS correlate accordingly with LV hemodynamics under various inotropic states in swine. Indexing strain parameters for indirect measures of afterload substantially improves this correlation, with GLS being as good as LV ejection fraction in reflecting LV contractility. CMR-FT-strain imaging may be a quick and promising tool to characterize LV hemodynamics in patients with varying degrees of LV dysfunction.

COVID-19 myocarditis and prospective heart failure burden

Introduction: COVID-19 is causing considerable morbidity and mortality worldwide. Serious respiratory complications aside, the heart is also frequently involved. The mechanisms and the extent of the myocardial injury, along with the short and long-term cardiovascular (CV) outcomes in COVID-19 survivors remain unclear. Areas covered: myocardial injury has been found in a considerable proportion of hospitalized COVID-19 patients and is associated with a worse prognosis. The late onset of CV complications with myocarditis-like changes revealed by CMR has been reported in COVID-19 survivors. Previous observational studies on viral myocarditis provide evidence of a significant incomplete recovery with residual dysfunction and remodeling of left ventricle. Incomplete recovery is thought to be the result of persistent myocardial inflammation due to a post-viral autoimmune response. Considering the significant inflammatory nature of COVID-19, COVID-19 survivors may be at risk of developing persistent residual myocardial injury, the sequelae of which are unclear. Expert commentary: COVID-19 is an emerging threat for the heart. The extent of CV injury, along with the short and long-term sequelae, requires further investigation. The early detection of residual myocardial changes in COVID-19 survivors is of utmost importance in order to identify those patients at risk of CV complication development.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), left ventricular (LV) filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

In-depth phenotyping of cardiac diseases by MRI in HIV-positive people reveals diverse and independent forms of myocardial involvement

Background

It is increasingly recognised that non-ischaemic and ischaemic myocardial involvement represent important drivers of cardiac diseases in people living with HIV (PLWH). Non-invasive measurements with cardiac magnetic resonance (CMR) directly inform on the type of myocardial damage.

Purpose

To screen for the prevalence and type of cardiovascular disease (CVD) in PLWH using stress CMR in a cohort with highly active antiretroviral therapy (HAART).

Methods

This prospective cross-sectional study enrolled consecutive PLWH undergoing standardised evaluation for CVD using imaging. All participants underwent a standardised CMR protocol in a 3 Tesla scanner for function and volumes (cine), stress perfusion (regadenosone), scar (late gadolinium enhancement (LGE)), diffuse fibrosis (native T1-mapping) and oedema (native T2-mapping). Blood samples were additionally collected prior to CMR.

Results

141 participants were identified (n=32 in category C/AIDS). 16 patients had previously documented (n=23) myocardial diseases: myocarditis, n=1 non-obstructive coronary artery disease (CAD), n=8 myocardial infarction, n=3 congestive heart failure, n=3, and arrhythmia, n=8. Mean value for hs-cTnT, CRP and NT-proBNP was 9±18ng/l, 0.3±0.6mg/l and 104±229ng/l. 14 subjects had impaired LV-EF (&lt;50%) and 35 presented borderline LV-EF (50–55%). Myocardial LGE was present in 28 patients: non-ischemic pattern, n=16, ischemic pattern, n=11, and both patterns, n=1. Two patients had relevant inducible ischaemia, whereas a pattern of microvascular disease (MVD) was found in 26 patients. 72 subjects had diffuse fibrosis and 25 had active inflammation. Elevated native T1/T2 was significantly associated with low (&lt;350/μl), current, and initial CD4-count (χ2=5.317, p=0.021; χ2=3.841, p=0.050), just as with category C/AIDS (χ2=4.949, p=0.026). Native T2 showed a significant correlation with initial CD4-count (r=−0.252, p=0.008) and current NT-proBNP (r=0.190, p=0.030), but not with other laboratory values.

Conclusions

CMR in PLWH reveal high prevalence of cardiac involvement, which is predominantly non-ischaemic inflammatory in origin. MVD is a major presentation compared to relevant ischaemia due to epicardial CAD. Individual cardiovascular risk assessment in PLWH using CMR may bear a potential for personalised treatment.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The German Centre for Cardiovascular Research (DZHK)

Myocardial fibrosis and inflammation are predictors of heart failure outcomes in people living with HIV

Background

People living with HIV (PLWH) have higher prevalence of heart failure (HF), which cannot be fully related to traditional cardiovascular disease (CVD) risk factor&lt; or coronary artery disease. Tissue characterisation by cardiac magnetic resonance (CMR), such as with T1 and T2 mapping, is a unique diagnostic approach to provide non-invasive insights into the underlying myocardial pathophysiology.

Purpose

To examine prognostic associations of CMR measures, conventional and modified CVD risk scores with HF outcome in PLWH on long-term highly active antiretroviral therapy (HAART).

Methods

Consecutive PLWH underwent prospectively standardized evaluation of HF using CMR, risk scores and blood markers. CMR protocol included T1 and T2 mapping, perfusion and scar imaging. MAGGIC, Framingham and D:A:D risk scores were collected. Primary HF endpoint was defined as hospitalization or mortality due to HF, and time-to-even analysis from the index CMR to the first event per patient was performed.

Results

141 PLWH (61% males, 48.0 [40.1–54.6] years, CD4 count 655 [411–909] cells/μl) were included. 16 HF events were observed (12 hospitalizations and 4 deaths) during a median follow-up of 13 [9–16] months. Baseline myocardial native T1, T2, left ventricular volumes and troponin were significant univariate predictors of the HF endpoint. The only signifcant (p&lt;0.001) independent predictor in the multivariate analysis was myocardial native T1 (T1 ≥4 SD, HR (95% CI): 5.0 [1.8–13.4]). Conventional and modified CVD risk scores showed no prognostic association with HF outcomes.

Conclusions

Our results show that presence and severity of myocardial inflammation and predominantly diffuse fibrosis detected by T2 and T1 mapping strongly relates to HF events in contrast to conventional and traditional CVD risk scores.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The German Centre for Cardiovascular Research (DZHK)