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Introduction: Utilization of cardiac magnetic resonance imaging (CMRI) has been increasing year by year for the most cardiovascular diseases. In this paper, we documented a real-life experience of our center as a high-volume CMRI performing center. Methods: We have retrospectively analyzed the 100 patients who have undergone CMRI at our center during the last 1 year. All the preliminary diagnoses, specialty or subspecialty of referring physicians, patient characteristics and CMRI findings were analyzed. Results: In 87 of 100 scans, a gadolinium-based contrast agent was used and in none of these procedures neither complications nor adverse events related to the contrast agent has occurred. Among these 100 consecutive CMRIs were referred to by a clinical cardiologist, invasive cardiologists, heart failure specialist, cardiovascular imaging specialists, electrophysiologists, and other specialists. On referral from a clinical cardiologist, the CMRI findings were high consistency. In these patients, the biggest number of preliminary diagnoses belongs to hypertrophic cardiomyopathy. The most common MRI finding was reduced left ventricular ejection fraction. In 25 patients we observed extracardiac findings. Conclusion: CMRI is increasingly occurring in cardiovascular imaging and diagnosis of various cardiovascular diseases. CMRI not only produces high-resolution morphological images but also provides quantitative information on the severity of reGürgitant or stenotic lesions in valvular diseases or cardiac shunts with the velocity and flow measurements.

Severe aortic stenosis (AS) is the most common valvular heart disease with a prevalence rate of more than 4% in 75-year-old people or older. Similarly, cardiac amyloidosis (CA), especially “wild-type transthyretin” (wTTR), has shown a prevalence rate ranging from 22% to 25% in people older than 80 years. The detection of the concomitant presence of CA and AS is challenging primarily because of the similar type of changes in the left ventricle caused by AS and CA, which share some morphological characteristics. The aim of this review is to identify the imaging triggers in order to recognize occult wtATTR-CA in patients with AS, clarifying the crucial step of the diagnostic process. Multimodality imaging methods such as echocardiography, cardiac magnetic resonance, cardiac computed tomography, and DPD scintigraphy will be analyzed as part of the available diagnostic workup to identify wtATTR-CA early in patients with AS.

Funder: Medical Research Council, Funder: British Heart Foundation, Funder: National Institute for Health Research (NIHR), INTRODUCTION: Inflammation plays a critical role in the pathogenesis of atherosclerosis, the leading cause of ischaemic heart disease (IHD). Studies in preclinical models have demonstrated that an increase in regulatory T cells (Tregs), which have a potent immune modulatory action, led to a regression of atherosclerosis. The Low-dose InterLeukin 2 (IL-2) in patients with stable ischaemic heart disease and Acute Coronary Syndromes (LILACS) study, established the safety of low-dose IL-2 and its biological efficacy in IHD. The IVORY trial is designed to assess the effects of low-dose IL-2 on vascular inflammation in patients with acute coronary syndromes (ACS). METHODS AND ANALYSIS: In this study, we hypothesise that low-dose IL-2 will reduce vascular inflammation in patients presenting with ACS. This is a double-blind, randomised, placebo-controlled, phase II clinical trial. Patients will be recruited across two centres, a district general hospital and a tertiary cardiac centre in Cambridge, UK. Sixty patients with ACS (unstable angina, non-ST elevation myocardial infarction or ST elevation myocardial infarction) with high-sensitivity C reactive protein (hsCRP) levels >2 mg/L will be randomised to receive either 1.5×106 IU of low-dose IL-2 or placebo (1:1). Dosing will commence within 14 days of admission. Dosing will comprise of an induction and a maintenance phase. 2-Deoxy-2-[fluorine-18] fluoro-D-glucose (18F-FDG) positron emission tomography/CT (PET/CT) scans will be performed before and after dosing. The primary endpoint is the change in mean maximum target to background ratios (TBRmax) in the index vessel between baseline and follow-up scans. Changes in circulating T-cell subsets will be measured as secondary endpoints of the study. The safety and tolerability of extended dosing with low-dose IL-2 in patients with ACS will be evaluated throughout the study. ETHICS AND DISSEMINATION: The Health Research Authority and Health and Care Research Wales, UK (19/YH/0171), approved the study. Written informed consent is required to participate in the trial. The results will be reported through peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: NCT04241601.

PURPOSE: We aimed to determine the prevalence rate and radiological characteristics of intra-atrial right coronary artery (IARCA) in an adult population undergoing computed tomography coronary angiography (CTCA) on a dual-source CT scanner. METHODS: Overall, 7114 consecutive CTCAs acquired using a dual-source CT scanner in a high-volume, specialized cardiac care facility were retrospectively analyzed for the presence of IARCA. We scrutinized the CTCA datasets to determine the prevalence rate of IARCA and also to characterize its various imaging features including its length, depth from right atrial wall, segment involved, and presence and absence of atherosclerosis within the involved segment and in the rest of the right coronary artery (RCA). RESULTS: The prevalence of IARCA was 0.29% (21/7114) in our study population. The mean length and depth of the intra-atrial segment was 14.85 mm and 2.57 mm, respectively. The mid-RCA was the most common segment to be involved, and no significant atherosclerosis was noted either in the intra-atrial segment or the rest of the RCA. CONCLUSION: The prevalence rate of the incidental IARCA in the adult subjects undergoing CTCA is higher than previously reported for anatomical series, as seen in our study using a dual-source scanner. This under-reported anomaly must be explicitly assessed in patients undergoing ablative and other electrophysiological procedures, where it can have important implications.

Objectives This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p, Central Illustration

Background and objectives: Myocardial infarction scar (MIS) assessment by cardiac magnetic resonance provides prognostic information and guides patients’ clinical management. However, MIS segmentation is time-consuming and not performed routinely. This study presents a deep-learning-based computational workflow for the segmentation of left ventricular (LV) MIS, for the first time performed on state-of-the-art dark-blood late gadolinium enhancement (DB-LGE) images, and the computation of MIS transmurality and extent. Methods: DB-LGE short-axis images of consecutive patients with myocardial infarction were acquired at 1.5T in two centres between Jan 1, 2019, and June 1, 2021. Two convolutional neural network (CNN) models based on the U-Net architecture were trained to sequentially segment the LV and MIS, by processing an incoming series of DB-LGE images. A 5-fold cross-validation was performed to assess the performance of the models. Model outputs were compared respectively with manual (LV endo- and epicardial border) and semi-automated (MIS, 4-Standard Deviation technique) ground truth to assess the accuracy of the segmentation. An automated post-processing and reporting tool was developed, computing MIS extent (expressed as relative infarcted mass) and transmurality. Results: The dataset included 1355 DB-LGE short-axis images from 144 patients (MIS in 942 images). High performance (> 0.85) as measured by the Intersection over Union metric was obtained for both the LV and MIS segmentations on the training sets. The performance for both LV and MIS segmentations was 0.83 on the test sets. Compared to the 4-Standard Deviation segmentation technique, our system was five times quicker (

Objective: To assess the potential therapeutic role of exercise on health-related quality of life, assessed by the Pediatric Outcomes Data Collection Instrument (PODCI), coronary flow reserve (CFR), cardiac function, cardiorespiratory fitness, and inflammatory and cardiac blood markers in multisystemic inflammatory syndrome in children (MIS-C) patients. Methods: This is a case series study of a 12-wk, home-based exercise intervention in children and adolescents after MIS-C diagnosis. From 16 MIS-C patients followed at our clinic, 6 were included (age: 7–16 years; 3 females). Three of them withdrew before the intervention and served as controls. The primary outcome was health-related quality of life, assessed PODCI. Secondary outcomes were CFR assessed by 13N-ammonia PET-CT imaging, cardiac function by echocardiography, cardiorespiratory fitness, and inflammatory and cardiac blood markers. Results: In general, patients showed poor health-related quality of life, which seemed to be improved with exercise. Additionally, exercised patients showed improvements in coronary flow reserve, cardiac function, and aerobic conditioning. Non-exercised patients exhibited a slower pattern of recovery, particularly in relation to health-related quality of life and aerobic conditioning. Conclusions: Our results suggest that exercise may play a therapeutic role in the treatment of post-discharge MIS-C patients. As our design does not allow inferring causality, randomized controlled trials are necessary to confirm these preliminary findings.

Purpose: this study was planned to assess the application of three-dimensional (3D) cardiac modeling in preoperative evaluation for complex congenital heart surgeries. Methods: from July 2015 to September 2019, 18 children diagnosed with complex congenital heart diseases (CHDs) were enrolled in this study (double outlet right ventricle in nine patients, complex types of transposition of the great arteries in six patients, congenitally corrected transposition of the great arteries in two patients, and univentricular heart in one patient). The patients' age ranged from 7 months to 19 years (median age, 14 months). Before the operation, 3D patient-specific cardiac models were created based on computed tomography (CT) data. Using each patient's data, a virtual computer model (3D mesh) and stereolithographic (SLA) file that would be printed as a 3D model were generated. These 3D cardiac models were used to gather additional data about cardiac anatomy for presurgical decision-making. Results: all 18 patients successfully underwent surgeries, and there were no mortalities. The 3D patient-specific cardiac models led to a change from the initial surgical plans in 6 of 18 cases (33%), and biventricular repair was considered feasible. Moreover, the models helped to modify the planned biventricular repair in five cases, for left ventricular outflow tract obstruction removal and ventricular septal defect enlargement. 3D cardiac models enable pediatric cardiologists to better understand the spatial relationships between the ventricular septal defect and great vessels, and they help surgeons identify risk structures more clearly for detailed planning of surgery. There was a strong correlation between the models of the patients and the anatomy encountered during the operation. Conclusion: 3D cardiac models accurately reveal the patient's anatomy in detail and are therefore beneficial for planning surgery in patients with complex intracardiac anatomy., NA

Objective Hyperglycaemia during pregnancy is associated with cardiometabolic risks for the mother and the offspring. Mothers with gestational diabetes mellitus (GDM) have signs of subclinical atherosclerosis, including increased carotid intima–media thickness (CIMT). We assessed whether GDM is associated with increased CIMT in the offspring at birth. Design and setting MySweetHeart Cohort is a prospective cohort study conducted in Switzerland. Participants, exposure and outcome measures This work included pregnant women with and without GDM at 24–32 weeks of gestation and their singleton live-born offspring with data on the primary outcome of CIMT. GDM was diagnosed based on the criteria of the International Association of Diabetes and Pregnancy Study Groups. Offspring’s CIMT was measured by ultrasonography after birth (range 1–19 days). Results Data on CIMT were available for 99 offspring of women without GDM and 101 offspring of women with GDM. Maternal age ranged from 18 to 47 years. Some 16% of women with GDM and 6% of women without GDM were obese. Smoking during pregnancy was more frequent among women with GDM (18%) than among those without GDM (4%). Neonatal characteristics were comparable between the two groups. The difference in CIMT between offspring of women with and without GDM was of 0.00 mm (95% CI −0.01 to 0.01; p=0.96) and remained similar on adjustment for potential confounding factors, such as maternal prepregnancy body mass index, maternal education, smoking during pregnancy, family history of diabetes, as well as offspring’s sex, age, and body surface area (0.00 mm (95% CI −0.02 to 0.01; p=0.45)). Conclusions We found no evidence of increased CIMT in neonates exposed to GDM. A longer-term follow-up that includes additional vascular measures, such as endothelial function or arterial stiffness, may shed further light on the cardiovascular health trajectories in children born to mothers with GDM. Trial registration number NCT02872974; Pre-results.

Cardioaortic embolism to the brain accounts for approximately 15–30% of ischaemic strokes and is often referred to as ‘cardioembolic stroke’. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain ‘cryptogenic’, recently redefined as ‘embolic strokes of undetermined source’. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging—transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)—in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.

Background Cardiovascular disease (CVD) can occur in COVID-19 and has impact on clinical course. Data on CVD prevalence in hospitalized COVID-19 patients and sequelae in survivors is limited. Aim of this prospective study carried out on consecutive unselected COVID-19 population, was to assess: 1) CVD occurrence among hospitalized COVID-19 patients, 2) persistence or new onset of CVD at one-month and one-year follow-up. Methods Over 30 days n = 152 COVID-19 patients underwent cardiovascular evaluation. Standard electrocardiogram (ECG), Troponin and echocardiography were integrated by further tests when indicated. Medical history, arterial blood gas, blood tests, chest computed tomography and treatment were recorded. CVD was defined as the occurrence of a new condition during the hospitalization for COVID-19. Survivors attended a one-month follow-up visit and a one-year telephone follow-up. Results Forty-two patients (28%) experienced a wide spectrum of CVD with acute myocarditis being the most frequent. Death occurred in 32 patients (21%) and more frequently in patients who developed CVD (p = 0.032). After adjustment for confounders, CVD was independently associated with death occurrence. At one-month follow-up visit, 7 patients (9%) presented persistent or delayed CVD. At one-year telephone follow-up, 57 patients (48%) reported persistent symptoms. Conclusion Cardiovascular evaluation in COVID-19 patients is crucial since the occurrence of CVD in hospitalized COVID-19 patients is common (28%), requires specific treatment and increases the risk of in-hospital mortality. Persistence or delayed presentation of CVD at 1-month (9%) and persistent symptoms at 1-year follow-up (48%) suggest the need for monitoring COVID-19 survivors., Graphical abstract Unlabelled Image

Cardiovascular imaging techniques, including echocardiography, nuclear cardiology, multi-slice computed tomography, and cardiac magnetic resonance, have wide applications in cardiac resynchronization therapy (CRT). Our aim was to provide an update of cardiovascular imaging applications before, during, and after implantation of a CRT device. Before CRT implantation, cardiovascular imaging techniques may integrate current clinical and electrocardiographic selection criteria in the identification of patients who may most likely benefit from CRT. Assessment of myocardial viability by ultrasound, nuclear cardiology, or cardiac magnetic resonance may guide optimal left ventricular (LV) lead positioning and help to predict LV function improvement by CRT. During implantation, echocardiographic techniques may guide in the identification of the best site of LV pacing. After CRT implantation, cardiovascular imaging plays an important role in the assessment of CRT response, which can be defined according to LV reverse remodeling, function and dyssynchrony indices. Furthermore, imaging techniques may be used for CRT programming optimization during follow-up, especially in patients who turn out to be non-responders. However, in the clinical settings, the use of proposed functional indices for different imaging techniques is still debated, due to their suboptimal feasibility and reproducibility. Moreover, identifying CRT responders before implantation and turning non-responders into responders at follow-up remain challenging issues.

Artificial intelligence (AI) has influenced every field of cardiovascular imaging in all phases from acquisition to reporting. Compared with computed tomography and magnetic resonance imaging, there is an issue of high observer variation in the interpretation of echocardiograms. Therefore, AI can help minimize the observer variation and provide accurate diagnosis in the field of echocardiography. In this review, we summarize the necessity for automated diagnosis in the echocardiographic field, and discuss the results of AI application to echocardiography and future perspectives. Currently, there are two roles for AI in cardiovascular imaging. One is the automation of tasks performed by humans, such as image segmentation, measurement of cardiac structural and functional parameters. The other is the discovery of clinically important insights. Most reported applications were focused on the automation of tasks. Moreover, algorithms that can obtain cardiac measurements are also being reported. In the next stage, AI can be expected to expand and enrich existing knowledge. With the continual evolution of technology, cardiologists should become well versed in this new knowledge of AI and be able to harness it as a tool. AI can be incorporated into everyday clinical practice and become a valuable aid for many healthcare professionals dealing with cardiovascular diseases. Electronic supplementary material The online version of this article (10.1007/s12574-020-00496-4) contains supplementary material, which is available to authorized users.

Purpose Earlier imaging techniques for coronary artery disease (CAD) focused primarily on either morphological or functional assessment of CAD. However, dual-energy computed tomography (DECT) can be used to assess myocardial blood supply both morphologically and functionally. We aimed to evaluate the diagnostic accuracy of DECT in detecting morphological and functional components of CAD, using invasive coronary angiography (ICA) and single photon emission computed tomography (SPECT) as reference standards. Methods Twenty-five patients with known or suspicious CAD and scheduled for ICA were investigated by DECT and SPECT. DECT was performed during the resting state using retrospective electrocardiography (ECG) gating. CT coronary angiography and perfusion images were generated from the same raw data. All patients were evaluated for significant stenosis (≥50%) on both ICA and DECT coronary angiography, and for myocardial perfusion defects on SPECT and DECT perfusion. Comparison was done between ICA and DECT coronary angiography for detection of significant stenosis and between SPECT and DECT perfusion for detecting myocardial perfusion defects. Results Using ICA as reference standard, sensitivity, specificity, and accuracy of DECT coronary angiography in detecting ≥50% stenosis of coronary artery lumen were 81.6%, 97.8%, and 95.0%, respectively, by segment-based analysis and 92.1%, 96.1%, and 93.7%, respectively, by vessel-based analysis. Using SPECT as the reference standard, the sensitivity, specificity, and accuracy of DECT perfusion in detecting myocardial perfusion defects were 70.4%, 86.4%, and 80.6%, respectively, on per-segment analysis and 90.7%, 66.6%, and 84.7%, respectively, on per-territorial basis. Conclusion DECT accurately detected coronary artery stenosis and myocardial ischemia using ICA and SPECT as reference standards. In the same scan, DECT can accurately provide integrative imaging of coronary artery morphology and myocardial perfusion.

PURPOSE: We aimed to determine the relationship of abnormal labyrinthine signals on heavily T2-weighted three-dimensional fluid-attenuated inversion recovery imaging (HF sequence) with hearing impairment and prognosis in patients with sudden sensorineural hearing loss (SSNHL). METHODS: Patients with unilateral SSNHL underwent magnetic resonance imaging, including pre-contrast HF sequences and post-contrast HF sequences with a 4-hour scan delay after intravenous gadolinium injection. We measured the signal intensity ratio (SIR) of the vestibule and cochlea relative to the cerebellar medulla on post-contrast HF sequences, and analyzed the relationship of SIR with hearing impairment and prognosis. RESULTS: Of 61 patients, 23 (37.7%) showed signal abnormalities on post-contrast HF sequences. Initial hearing loss and hearing recovery were worse in the HF+ group than in the HF− group (P < 0.05). Profound hearing loss was more common in the HF+ group (52.2% vs. 23.7%), while moderate hearing loss was more common in the HF− group (18.4% vs. 0.0%; P < 0.05 for both). The rate of partial recovery was higher in the HF− group (42.1%) than in the HF+ group (13.0%; P < 0.05). The SIRs of the vestibule and cochlea were positively correlated with the severity of hearing loss and hearing recovery, with higher SIRs indicating more severe hearing loss and poor recovery. CONCLUSION: Labyrinthine signal abnormalities were found on post-contrast HF sequences in 37.7% of patients with SSNHL. These abnormalities were found only in patients with severe-to-profound hearing loss. Increased SIR indicated more severe hearing loss and poor prognosis.

The coronavirus disease 2019 (COVID-19) pandemic created an unprecedented disruption to routine patient care ([1][1]). Health care professionals scrambled within weeks to attend to the surge of affected individuals amid concerns of hospital capacity and scarcity of personal protective equipment (PPE

The aim of this study is to simultaneously quantify T1/T2 across three slices of the left-ventricular myocardium without breath-holds or ECG monitoring, all within a 3 min scan. Radial simultaneous multi-slice (SMS) encoding, self-gating, and image reconstruction was incorporated into the cardiovascular magnetic resonance (CMR) Multitasking framework to simultaneously image three short-axis slices. A T2prep-IR FLASH sequence with two flip angles was designed and implemented to allow B1+-robust T1 and T2 mapping. The proposed Multitasking-SMS method was validated in a standardized phantom and 10 healthy volunteers, comparing T1 and T2 measurements and scan-rescan repeatability against corresponding reference methods in one layer of phantom vials and in 16 American Heart Association (AHA) myocardial segments. In phantom, Multitasking-SMS T1/T2 measurements showed substantial correlation (R2> 0.996) and excellent agreement [intraclass correlation coefficients (ICC) ≥ 0.999)] with reference measurements. In healthy volunteers, Multitasking-SMS T1/T2 maps reported similar myocardial T1/T2 values (1,215 ± 91.0/41.5 ± 6.3 ms) to the reference myocardial T1/T2 values (1,239 ± 67.5/42.7 ± 4.1 ms), withP= 0.347 andP= 0.296, respectively. Bland–Altman analyses also demonstrated goodin vivorepeatability in both the multitasking and references, with segment-wise coefficients of variation of 4.7% (multitasking T1), 8.9% (multitasking T2), 2.4% [modified look-locker inversion recovery (MOLLI)], and 4.6% (T2-prep FLASH), respectively. In summary, multitasking-SMS is feasible for free-breathing, non-ECG, myocardial T1/T2 quantification in 16 AHA segments over 3 short-axis slices in 3 min. The method shows the great potential for reducing exam time for quantitative CMR without ECG or breath-holds.

Aims Despite being a common finding in hospitalized COVID-19 patients, cardiac troponin elevation remains a nonspecific detection of myocardial injury and further in-hospital investigation into the cause of myocardial injury is rarely done. COVID-19 patients with myocardial injury show a significantly higher in-hospital mortality rate compared with those without myocardial injury and among those with myocardial injury, greater degrees of troponin elevation are associated with higher mortality rates. There are still many questions regarding possible cardiovascular sequelae and prognostic significance in these patients. Being able to distinguish between inflammatory and ischaemic causes of myocardial injury cardiovascular magnetic resonance (CMR) is the non-invasive modality of choice to investigate myocardial involvement in these patients. Presented are the preliminary single-centre results from a multicentre study aimed to characterize the prevalence, type and extent of COVID-19-related cardiovascular sequelae using CMR imaging. Methods and results In this single-centre prospective observational cohort study, patients hospitalized with confirmed COVID-19 and at least one value of high sensitivity I troponin (hs-Tnl) >99th percentile during hospitalization were eligible for follow-up contrast-enhanced CMR imaging. Patients with any standard CMR contraindications were excluded. Images were acquired using a standardized myocarditis protocol including late gadolinium enhancement (LGE) and T1 and T2 mapping. Cutoff values of 1015 ms and 50 ms were used for abnormal T1 and T2 measurements, respectively. Of the 21 patients (65 ± 11.85 years) who underwent imaging, 15 (71.4%) were male. The mean follow-up duration from the date of confirmed COVID-19 diagnosis was 169 ± 19 days. The mean left ventricular ejection fraction was 64.1 ± 13.87 and 3 (14.3%) patients had evidence of wall motion abnormalities. LGE was seen in 9/20 (45.0%) patients, reflecting myocardial fibrosis. Increased native T1 signal representing myocardial fibrosis and/or oedema was seen in 9/20 (45.0%) patients. While increased native T2 signal, being more specific for oedema was observed in 3/20 (15.0%) patients. Considering CMR findings, 6 (28.6%) patients showed evidence of previous myocarditis. Conclusions In this single centre Italian study of patients hospitalized with COVID-19 and elevated cardiac enzymes, myocarditis-like injury was evident in about a quarter of the patients. Whether these findings will lead to long-term cardiac complications is still to be confirmed.

Background This study aimed to investigate the association between changes in brain natriuretic peptide (BNP) from discharge to 6-month visit and subsequent clinical outcomes in patients with acute heart failure (AHF). Methods Among 1246 patients enrolled in the prospective longitudinal follow-up study nested from the Kyoto Congestive Heart Failure registry, this study population included 446 patients with available paired BNP data at discharge and 6-month index visit. This study population was classified into 3 groups by percent change in BNP from discharge to 6-month visit; the low tertile (≤-44%, N = 149), the middle tertile (>-44% and ≤22%, N = 149) and the high tertile (>22%, N = 148). Findings The cumulative 180-day incidence after the index visit of the primary outcome measure (a composite endpoint of all-cause death or hospitalization for HF) was significantly higher in the high and middle tertiles than in the low tertile (26.8% and 14.4% versus 6.9%, log-rank P Conclusions Percent change in BNP was associated with a subsequent risk for a composite of all-cause death and hospitalization for HF after adjustment of the absolute BNP values, suggesting that observing the change in BNP levels, in addition to absolute BNP levels themselves, helps us to manage patient with HF.

Exercise improves measures of cardiovascular (CV) health and function. But as traditional measures improve gradually, it can be difficult to identify the effectiveness of an exercise intervention in the short-term. Left ventricular global longitudinal strain (LVGLS) is a highly sensitive CV imaging measure that detects signs of myocardial dysfunction prior to more traditional measures, with reductions in LVGLS a strong prognostic indicator of future CV dysfunction and mortality. Due to its sensitivity, LVGLS may offer useful method of tracking the effectiveness of an exercise intervention on CV function in the short-term, providing practitioners useful information to improve patient care in exercise settings. However, the effect of exercise on LVGLS is unclear. This systematic review and meta-analysis aimed to determine the effect exercise has on LVGLS across a range of populations. Included studies assessed LVGLS pre–post an exercise intervention (minimum 2 weeks) in adults 18 years and over, and were published in English from 2000 onwards. Study-level random-effects meta-analyses were performed using Stata (v16.1) to calculate summary standardized mean differences (SMD) and 95% confidence intervals (CI). 39 studies met selection criteria, with 35 included in meta-analyses (1765 participants). In primary analyses, a significant improvement in LVGLS was observed in populations with CV disease (SMD = 0.59; 95% CI 0.16–1.02; p = 0.01), however, no significant effect of exercise was observed in CV risk factor and healthy populations. In populations with CV disease, LVGLS could be used as an early biomarker to determine the effectiveness of an exercise regime before changes in other clinical measures are observed.

IntroductionAchieving optimal placement of the left ventricular (LV) lead in cardiac resynchronisation therapy (CRT) is a prerequisite in order to achieve maximum clinical benefit, and is likely to help avoid non-response. Pacing outside scar tissue and targeting late activated segments may improve outcome. The present study will be the first randomised controlled trial to compare the efficacy of real-time image-guided LV lead delivery to conventional CRT implantation. In addition, to estimate the cost-effectiveness of targeted lead implantation, an early decision analytic model was developed, and described here.Methods and analysisA multicentre, interventional, randomised, controlled trial will be conducted in a total of 130 patients with a class I or IIa indication for CRT implantation. Patients will be stratified to ischaemic heart failure aetiology and 1:1 randomised to either empirical lead placement or live image-guided lead placement. Ultimate lead location and echocardiographic assessment will be performed by core laboratories, blinded to treatment allocation and patient information. Late gadolinium enhancement cardiac magnetic resonance imaging (CMR) and CINE-CMR with feature-tracking postprocessing software will be used to semi-automatically determine myocardial scar and late mechanical activation. The subsequent treatment file with optimal LV-lead positions will be fused with the fluoroscopy, resulting in live target-visualisation during the procedure. The primary endpoint is the difference in percentage of successfully targeted LV-lead location. Secondary endpoints are relative percentage reduction in indexed LV end-systolic volume, a hierarchical clinical endpoint, and quality of life. The early analytic model was developed using a Markov-model, consisting of seven mutually exclusive health states.Ethics and disseminationThe protocol was approved by the Medical Research Ethics Committee Utrecht (NL73416.041.20). All participants are required to provide written informed consent. Results will be submitted to peer-reviewed journals.Trial registration numberNCT05053568; Trial NL8666.

Background Measurement of cardiac structure and function from images (e.g. volumes, mass and derived parameters such as left ventricular (LV) ejection fraction [LVEF]) guides care for millions. This is best assessed using cardiovascular magnetic resonance (CMR), but image analysis is currently performed by individual clinicians, which introduces error. We sought to develop a machine learning algorithm for volumetric analysis of CMR images with demonstrably better precision than human analysis. Methods A fully automated machine learning algorithm was trained on 1923 scans (10 scanner models, 13 institutions, 9 clinical conditions, 60,000 contours) and used to segment the LV blood volume and myocardium. Performance was quantified by measuring precision on an independent multi-site validation dataset with multiple pathologies with n = 109 patients, scanned twice. This dataset was augmented with a further 1277 patients scanned as part of routine clinical care to allow qualitative assessment of generalization ability by identifying mis-segmentations. Machine learning algorithm (‘machine’) performance was compared to three clinicians (‘human’) and a commercial tool (cvi42, Circle Cardiovascular Imaging). Findings Machine analysis was quicker (20 s per patient) than human (13 min). Overall machine mis-segmentation rate was 1 in 479 images for the combined dataset, occurring mostly in rare pathologies not encountered in training. Without correcting these mis-segmentations, machine analysis had superior precision to three clinicians (e.g. scan-rescan coefficients of variation of human vs machine: LVEF 6.0% vs 4.2%, LV mass 4.8% vs. 3.6%; both P Conclusion We present a fully automated algorithm for measuring LV structure and global systolic function that betters human performance for speed and precision.

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-U.S. institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection.

The COVID-19 pandemic and its impact on patients with cancer and cardiovascular disease have confirmed the particular vulnerability of these populations. Indeed, not only a higher risk of contracting the infection has been reported but also an increased occurrence of a more severe course and unfavourable outcome. Beyond the direct consequences of COVID-19 infection, the pandemic has an enormous impact on global health systems. Screening programmes and non-urgent tests have been postponed; clinical trials have suffered a setback. Similarly, in the area of cardiology care, a significant decline in STEMI accesses and an increase in cases of late presenting heart attacks with increased mortality and complication rates have been reported. Health care systems must therefore get ready to tackle the ‘rebound effect’ that will likely show a relative increase in the short- and medium-term incidence of diseases such as heart failure, myocardial infarction, arrhythmias, and cardio- and cerebrovascular complications. Scientific societies are taking action to provide general guidance and recommendations aimed at mitigating the unfavourable outcomes of this pandemic emergency. Cardio-oncology, as an emerging discipline, is more flexible in modulating care pathways and represents a beacon of innovation in the development of multi-specialty patient management. In the era of the COVID-19 pandemic, cardio-oncology has rapidly modified its clinical care pathways and implemented flexible monitoring protocols that include targeted use of cardiac imaging, increased use of biomarkers, and telemedicine systems. The goal of these strategic adjustments is to minimize the risk of infection for providers and patients while maintaining standards of care for the treatment of oncologic and cardiovascular diseases. The aim of this document is to evaluate the impact of the pandemic on the management of cardio-oncologic patients with the-state-of-the-art knowledge about severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease (COVID-19) in order to optimize medical strategies during and after the pandemic.

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Purpose To investigate the differences in the choroidal biomarkers between two forms of flat irregular pigment epithelial detachment (FIPED): avascular (aFIPED) and vascularized (vFIPED) in eyes with chronic central serous chorioretinopathy (CSC). Materials and methods Enhanced depth imaging optical coherence tomography (EDI-OCT) was done in eyes with FIPED correlated to chronic CSC, fellow eyes, and also in healthy eyes from gender- and age-matched subjects. Eyes with FIPED were classified into two subgroups based on optical coherence tomography angiography (OCTA) findings: vFIPED and aFIPED. Different choroidal biomarkers such as subfoveal choroidal thickness (SFCT), total choroidal area (TCA), and choroidal vascular index (CVI) were compared between the groups. Results Forty-four eyes from 42 patients with chronic CSC and FIPED along with 40 eyes from 20 healthy subjects were included. OCTA identified vascularization in 14 eyes in the FIPED group (31.8%). Mean SFCT was higher in the FIPED group compared to two other groups (p = 0.005). In comparison to patients with aFIPED, patients with vFIPED had lower SFCT (p = 0.003) and higher CVI (p = 0.020) based on multivariate analysis. Conclusions It seems that measurement of CVI along with SFCT may help to differentiate aFIPED from vFIPED in patients with CSC. Further longitudinal studies would be required to confirm the clinical significance of these findings.

Background Myocardial perfusion imaging (MPI) is a well-established diagnostic tool to evaluate coronary artery disease (CAD) and also an effective prognostic tool for patients with CAD. However, few studies investigated the prognostic value of attenuation correction (AC) in MPI, and the results were controversial. Objectives To investigate the prognostic value of computed tomography (CT)-based AC thallium-201 (Tl-201) MPI. Methods A total of 108 consecutive patients who underwent Tl-201 MPI and received coronary angiography within 90 days were included. Medical records were reviewed and missing information was completed after telephone contact. The prognostic value was evaluated by Kaplan-Meier analysis, univariable and multivariable Cox proportional hazards model. Results After a mean follow-up of 7.72 ± 3.72 years, 27 patients had died, 41 had been readmitted for cardiovascular (CV)-related events and 44 had reached the composite of death plus CV-related re-admission. Kaplan-Meier curves for all-cause mortality for SSS with a cutoff value of 13 for AC and 16 for non-AC (NAC) images showed a significant difference between the two curves for both AC and NAC images (p = 0.011 for AC and p = 0.021 for NAC). In the multivariable model, SSS and SRS showed similar independent predictive values in predicting all-cause mortality and composite of all-cause mortality plus CV-related re-admission, in both AC and NAC images. Subgroup analysis implicated that AC MPI possibly provided better risk stratification in obese patients. Conclusion CT-based AC and NAC MPI showed similar value and were the only significant predictors for the composite of mortality and CV events.

PURPOSE: We aimed to determine if the image quality and vascular enhancement are preserved in computed tomography pulmonary angiography (CTPA) studies performed with ultra-low contrast and optimized radiation dose using high-pitch helical mode of a second generation dual source scanner. METHODS: We retrospectively evaluated oncology patients who had CTPA on a 128-slice dual-source scanner, with a high-pitch helical mode (3.0), following injection of 30 mL of Ioversal at 4 mL/s with body mass index (BMI) dependent tube potential (80–120 kVp) and current (130–150 mAs). Attenuation, noise, and signal-to-noise ratio (SNR) were measured in multiple pulmonary arteries. Three independent readers graded the images on a 5-point Likert scale for central vascular enhancement (CVE), peripheral vascular enhancement (PVE), and overall quality. RESULTS: There were 50 males and 101 females in our study. BMI ranged from 13 to 38 kg/m(2) (22.8±4.4 kg/m(2)). Pulmonary embolism was present in 29 patients (18.9%). Contrast enhancement and SNR were excellent in all the pulmonary arteries (395.3±131.1 and 18.3±5.7, respectively). Image quality was considered excellent by all the readers, with average reader scores near the highest possible score of 5.0 (CVE, 4.83±0.48; PVE, 4.68±0.65; noise/quality, 4.78±0.47). The average radiation dose length product (DLP) was 161±60 mGy.cm. CONCLUSION: Using a helical high-pitch acquisition technique, CTPA images of excellent diagnostic quality, including visualization of peripheral segmental/sub-segmental branches can be obtained using an ultra-low dose of iodinated contrast and low radiation dose.

PURPOSE: We aimed to evaluate Vieussens’ arterial ring (VAR) variants by consecutive coronary computed tomography (CT) angiography examinations. METHODS: We retrospectively evaluated the presence of VAR in a total of 3443 consecutive coronary CT angiography examinations performed between November 2010 and January 2015. CT examinations were performed with a 64-row multidetector computed tomography (MDCT) scanner. All CT angiography images were evaluated for the presence and morphologic features of VAR subtypes. VAR variants were classified into four subgroups. RESULTS: Eleven VAR variations (3.19‰) were identified. Type 1A was the most common VAR type (n=8), followed by Type 2 (n=2) and Type 3 (n=1). Type 1B was not detected. CONCLUSION: Although VAR variation is less frequently detected with coronary CT angiography than in previously reported anatomic series, coronary CT angiography is quite effective to reveal VAR subtypes and other relevant cardiocoronary anomalies.

PURPOSE We aimed to analyze multislice computed tomography (MSCT) imaging features of vasculitis in immunoglobulin G4-related disease (IgG4-RD). METHODS In this retrospective study, we diagnosed 21 definite or possible IgG4-RD patients (71.4% male; mean age, 52.1±4.5 years) with vasculitis by MSCT and pathologic examination. The clinical background, laboratory analysis, pathologic results, CT images, and response to therapy were assessed and analyzed. RESULTS Under enhanced MSCT, 50 vasculitic lesions were identified and were divided into five types (types A-E) according to the CT findings on the basis of luminal changes. There were more vasculitic lesions observed below the diaphragm (n=30) than above it (n=20). Aneurysms and aneurysmal dilatation were more likely to be found in the aortaventralis (n=5), aortic arch (n=3) and iliac arteries (n=3). Most of the vascular lesions were characterized by wall thickening with a normal lumen (n=15) and slight stenosis (n=22). The affected vascular walls were all thickened between 4 and 18 mm. The walls of 19 patients (90.4%) were well circumscribed. The wall thickness of the aorta, including the aortaventralis and aortic arch, was more notable than that of the other vascular sites. Fourteen patients were followed up for 2-24 months. Wall thickness decreased in all cases. The average maximum thicknesses before and after therapy were 12.2±2.7 mm and 6.1±1.8 mm, which were significantly different (P < 0.001). The lumens of two patients were found to be slightly enlarged, while those of the other cases were unchanged after therapy. CONCLUSION IgG4-RD vascular lesions can be divided into five types, which are more likely to be present in the aorta and its main branches, and can rapidly diminish after steroid therapy. The lumen may be unchanged or slightly enlarged.

PURPOSE The underlying diagnosis in patients with acute coronary syndrome (ACS) and unobstructed coronary arteries remains a diagnostic challenge. We analyzed the value of magnetic resonance imaging (MRI) in this clinical setting. METHODS A total of 213 patients with ACS and unobstructed coronary arteries underwent MRI within a median of 2 days after initial presentation. Clinical, laboratory, and MRI data were analyzed. A consensus diagnosis was established for each case by an independent panel after reviewing the individual clinical, laboratory, and MRI data. Standardized interviews to determine patient outcomes were carried out after a median follow-up of 24 months. Clinical events were defined as a composite of death, stroke, myocardial infarction or recurrence of Takotsubo syndrome (TTS), new onset of heart failure with a left ventricular ejection fraction (LVEF)

Background Patients with psoriasis have increased risk of cardiovascular disease (CVD) independent of traditional risk factors. The molecular mechanisms underlying the psoriasis-CVD connection are not fully understood. Advances in high-throughput molecular profiling technologies and computational analysis techniques offer new opportunities to improve the understanding of disease connections. Objective We aim to characterize the complexity of cardiovascular risk in patients with psoriasis by integrating deep phenotypic data with systems biology techniques to perform comprehensive multiomic analyses and construct network models of the two interacting diseases. Methods The study aims to include 120 adult patients with psoriasis (60 with prior atherosclerotic CVD and 60 without CVD). Half of the patients are already receiving systemic antipsoriatic treatment. All patients complete a questionnaire, and a medical interview is conducted to collect medical history and information on, for example, socioeconomics, mental health, diet, and physical exercise. Participants are examined clinically with assessment of the Psoriasis Area and Severity Index and undergo imaging by transthoracic echocardiography, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT), and carotid artery ultrasonography. Skin swabs are collected for analysis of microbiome metagenomics; skin biopsies and blood samples are collected for transcriptomic profiling by RNA sequencing; skin biopsies are collected for immunohistochemistry; plasma samples are collected for analyses of proteomics, lipidomics, and metabolomics; blood samples are collected for high-dimensional mass cytometry; and feces samples are collected for gut microbiome metagenomics. Bioinformatics and systems biology techniques are utilized to analyze the multiomic data and to integrate data into a network model of CVD in patients with psoriasis. Results Recruitment was completed in September 2020. Preliminary results of 18F-FDG-PET/CT data have recently been published, where vascular inflammation was reduced in the ascending aorta (P=.046) and aortic arch (P=.04) in patients treated with statins and was positively associated with inflammation in the visceral adipose tissue (P Conclusions This systems biology approach with integration of multiomics and clinical data in patients with psoriasis with or without CVD is likely to provide novel insights into the biological mechanisms underlying these diseases and their interplay that can impact future treatment. International Registered Report Identifier (IRRID) DERR1-10.2196/28669

Fluorescence lifetime imaging (FLIm) is an optical spectroscopic imaging technique capable of real-time assessments of tissue properties in clinical settings. Label-free FLIm is sensitive to changes in tissue structure and biochemistry resulting from pathological conditions, thus providing optical contrast to identify and monitor the progression of disease. Technical and methodological advances over the last two decades have enabled the development of FLIm instrumentation for real-time, in situ, mesoscopic imaging compatible with standard clinical workflows. Herein, we review the fundamental working principles of mesoscopic FLIm, discuss the technical characteristics of current clinical FLIm instrumentation, highlight the most commonly used analytical methods to interpret fluorescence lifetime data, and discuss the recent applications of FLIm in surgical oncology and cardiovascular diagnostics. Finally, we conclude with an outlook on the future directions of clinical FLIm. This article is protected by copyright. All rights reserved.

Objective To investigate the effects of axial length (AL) on the peripapillary microvascular density acquired from optical coherence tomography angiography (OCTA). Methods Retrospective observational study. A total of 111 eyes from 111 normal healthy subjects were examined. The subjects were divided into three groups according to the AL: Group 1 (AL: < 24.0 mm; 35 eyes), Group 2 (AL: 24.0–25.99 mm; 37 eyes), and Group 3 (AL: ≥ 26 mm; 39 eyes). Peripapillary OCTA images were acquired using 6× 6 mm angiography scans, and vessel density (VD) and perfusion density (PD) of the superficial capillary plexus were calculated automatically. VD and PD were compared among the three groups according to the distance from the optic disc (inner and outer rings). Linear regression analyses were also performed to identify clinical factors associated with average VD. Results The average ALs of Groups 1–3 were 23.33± 0.57, 25.05± 0.60, and 27.42± 0.82, respectively. Average VD (P = 0.009) and PD (P = 0.029) in the inner ring increased with increasing AL. However, average VD (P < 0.001) and PD (P < 0.001) in the outer ring decreased with AL increased; the same trends were found for the full areas (VD, p Conclusions Peripapillary VD and PD were significantly associated with AL. Depending on the distance from the disc, peripapillary VDs and PDs of the inner and outer rings were differentially affected by AL. Physicians should therefore consider the effects of AL in the analyses of peripapillary microvasculature.

Surgery in humans is continuously evolving and promoted minimally invasive treatment. On the other hand, despite the importance of the 3Rs principles for experimental animals is well documented, no reports describe specific methodologies for implementing "refinement" in practice. Here, we describe a new technique, the "Ohta Method" for caudal arthrocentesis in the pursuit of the 3Rs for animal experiments and the development of innovative methods for investigating systemic organ arteries through minimally invasive procedures. This procedure requires only a percutaneous puncture of the caudal artery without any injury to the limb or body trunk. In addition, it does not cut down the artery, making hemostasis easier and recovering arterial damage easier. We will show multiple organ artery angiographies in marmoset for the first time in the world. The principle described in this paper could also be applied to many other small animals, such as rats. Moreover, using this method, multiple doses of the drug or cells can be administered to the target organ at the time of therapeutic intervention, thereby enabling the establishment of more sophisticated and complex therapeutic intervention studies as translational research.

Percutaneous transluminal angioplasty (PTA) is considered an effective treatment in patients with critical limb ischemia (CLI). However, the long-term durability of below-the-knee (BTK) PTA is known to be limited. This study sought to compare the 1-year clinical outcomes following stenting versus balloon angioplasty alone in BTK lesions. This study included 357 consecutive patients (400 limbs, 697 lesions) with BTK lesions who underwent PTA from September 2010 to December 2016. All enrolled patients were treated either by stenting (stent group; 111 limbs of 102 patients) or plain old balloon angioplasty (POBA group; 289 limbs of 255 patients). Stent group includes both primary and provisional stenting. Angiographic outcomes, procedural success, complications, and clinical outcomes were compared between the two groups up to 1 year. After propensity score matching (PSM) analysis, 56 pairs were generated, and the baseline and angiographic characteristics were balanced. The procedural success and complications were similar between the two groups; however, the incidence of procedure-related perforation was higher in the POBA group than in the stenting group [5(11.9%) vs.1 (0.9%), P = 0.009]. Six- to 9-month computed tomography or angiographic follow-up showed similar incidences of binary restenosis, primary patency, and secondary patency. In the 1-year clinical follow-up, there were similar incidences of individual hard endpoints, including mortality, myocardial infarction, limb salvage, and amputation rate, with the exception of target extremity revascularization (TER), which tended to be higher in the stenting group than in the POBA group [21 (20.8%) vs. 11 (10.9%), P = 0.054]. Although there was a trend toward a higher incidence of TER risk in the stenting group, stent implantation, particularly in bail-out stenting seemed to have acceptable 1-year safety and efficacy compared to POBA alone in patients undergoing BTK PTA.

Background Micro-computed tomography (micro-CT) constitutes an emerging imaging technique, which can be utilized in cardiovascular medicine to study in-detail the microstructure of heart and vessels. This paper aims to systematically review the clinical utility of micro-CT in cardiovascular imaging and propose future applications of micro-CT imaging in cardiovascular research. Methods A systematic scoping review was conducted by searching for original studies written in English according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. Medline, Scopus, ClinicalTrials.gov , and the Cochrane library were systematically searched through December 11, 2020 to identify publications concerning micro-CT applications in cardiovascular imaging. Preclinical-animal studies and case reports were excluded. The Newcastle-Ottawa assessment scale for observational studies was used to evaluate study quality. Results In total, the search strategy identified 30 studies that report on micro-CT–based cardiovascular imaging and satisfy our eligibility criteria. Across all included studies, the total number of micro-CT scanned specimens was 1,227. Six studies involved postmortem 3D-reconstruction of congenital heart defects, while eleven studies described atherosclerotic vessel (coronary or carotid) characteristics. Thirteen other studies employed micro-CT for the assessment of medical devices (mainly stents or prosthetic valves). Conclusion Micro-CT is a novel imaging modality, effectively adapted for the 3D visualization and analysis of cardiac soft tissues and devices at high spatial resolution. Its increasing use could make significant contributions to our improved understanding of the histopathophysiology of cardiovascular diseases, and thus has the potential to optimize interventional procedures and technologies and improving patient outcomes.

OBJECTIVE To investigate the accuracy of the Agatston score obtained with the ultra-high-pitch (UHP) acquisition mode using tin-filter spectral shaping (Sn150 kVp) and a kVp-independent reconstruction algorithm to reduce the radiation dose. MATERIALS AND METHODS This prospective study included 114 patients (mean ± standard deviation, 60.3 ± 9.8 years; 74 male) who underwent a standard 120 kVp scan and an additional UHP Sn150 kVp scan for coronary artery calcification scoring (CACS). These two datasets were reconstructed using a standard reconstruction algorithm (120 kVp + Qr36d, protocol A; Sn150 kVp + Qr36d, protocol B). In addition, the Sn150 kVp dataset was reconstructed using a kVp-independent reconstruction algorithm (Sn150 kVp + Sa36d, protocol C). The Agatston scores for protocols A and B, as well as protocols A and C, were compared. The agreement between the scores was assessed using the intraclass correlation coefficient (ICC) and the Bland-Altman plot. The radiation doses for the 120 kVp and UHP Sn150 kVp acquisition modes were also compared. RESULTS No significant difference was observed in the Agatston score for protocols A (median, 63.05; interquartile range [IQR], 0-232.28) and C (median, 60.25; IQR, 0-195.20) (p = 0.060). The mean difference in the Agatston score for protocols A and C was relatively small (-7.82) and with the limits of agreement from -65.20 to 49.56 (ICC = 0.997). The Agatston score for protocol B (median, 34.85; IQR, 0-120.73) was significantly underestimated compared with that for protocol A (p < 0.001). The UHP Sn150 kVp mode facilitated an effective radiation dose reduction by approximately 30% (0.58 vs. 0.82 mSv, p < 0.001) from that associated with the standard 120 kVp mode. CONCLUSION The Agatston scores for CACS with the UHP Sn150 kVp mode with a kVp-independent reconstruction algorithm and the standard 120 kVp demonstrated excellent agreement with a small mean difference and narrow agreement limits. The UHP Sn150 kVp mode allowed a significant reduction in the radiation dose.

Purpose To analyze ocular biometric parameters alterations of the posterior pole and choroidal abnormalities in patients with neurofibromatosis type 1 (NF1) by adopting multimodal imaging, especially focusing on the role of novel diagnostic devices like swept-source optical coherence tomography angiography (SS-OCTA). Methods In this prospective, case-controlled study, patients with NF1 and age-matched control subjects were quantitatively analyzed by using multimodal imaging. All the subjects underwent confocal scanning laser ophthalmoscopy (SLO), SS-OCT and SS-OCTA examinations. Results SS-OCT analysis revealed a lower macular retinal nerve fiber layer (RNFL) thickness in patients with NF1 compared with those with suspected NF1 (95.0±15.9 vs 109.7±11.3 μm; P = 0.001) and control subjects (106.8±14.4 μm, P = 0.003). Retinal thickness was significantly lower in NF1 patients compared to those with suspected NF1 (280.7±23.0 vs 304.2±15.3 μm; P < 0.001) and control subjects (298.7±23.8 μm, P = 0.003). The mean vascular flow area of the SCP was significantly higher in patients with NF1 (42.6±2.2%) and suspected NF1 (43.1±2.5%) compared to control subjects (41.0±2.0%; respectively, P = 0.017 and P = 0.002). In the second choroidal layer, the flow area was significantly lower in patients with NF1 compared to control subjects (45.4±4.8 vs 49.0±4.0%,; P = 0.011). Conclusions Retinal thicknesses alterations and choroidal nodules are described as ocular manifestations in patients with NF1. In addition, OCTA could represent an important novel advanced imaging technique, capable of detecting early altered retinal and choroidal vascular flow area in patients with NF1.

The purpose of this review is to explore how metabolomics can help uncover new biomarkers and mechanisms for cardiovascular ageing. Cardiovascular ageing refers to cardiovascular structural and functional alterations that occur with chronological ageing and that can lead to the development of cardiovascular disease. These alterations, which were previously only detectable on tissue histology or corroborated on blood samples, are now detectable with modern imaging techniques. Despite the emergence of powerful new imaging tools, clinical investigation into cardiovascular ageing is challenging because ageing is a life course phenomenon involving known and unknown risk factors that play out in a dynamic fashion. Metabolomic profiling measures large numbers of metabolites with diverse chemical properties. Metabolomics has the potential to capture changes in biochemistry brought about by pathophysiologic processes as well as by normal ageing. When combined with non‐invasive cardiovascular imaging tools, metabolomics can be used to understand pathological consequences of cardiovascular ageing. This review will summarize previous metabolomics and imaging studies in cardiovascular ageing. These methods may be a clinically relevant and novel approach to identify mechanisms of cardiovascular ageing and formulate or personalize treatment strategies.

Anomalous origin of the coronary artery from the pulmonary artery is a rare and potentially fatal congenital heart defect. Up to 90% of infants with an anomaly involving the left coronary artery die within the first year of life if left untreated. Patients who survive beyond infancy are at risk of sudden cardiac death. Cardiac CT and MRI are increasingly being used for the accurate diagnosis of this anomaly for prompt surgical restoration of the dual coronary artery system. Moreover, life-long imaging surveillance after surgery is necessary for these patients. In this pictorial review, multimodal cardiac imaging findings of this rare and potentially fatal coronary artery anomaly are comprehensively discussed, and representative images are provided to facilitate the understanding of this anomaly.

OBJECTIVES This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-U.S. institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. BACKGROUND The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. METHODS Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. RESULTS Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p 1/4 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. CONCLUSIONS We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection. (C) 2021 by the American College of Cardiology Foundation.

Optical coherence tomography angiography (OCTA) performs non-invasive visualization and characterization of microvasculature in research and clinical applications mainly in ophthalmology and dermatology. A wide variety of instruments, imaging protocols, processing methods and metrics have been used to describe the microvasculature, such that comparing different study outcomes is currently not feasible. With the goal of contributing to standardization of OCTA data analysis, we report a user-friendly, open-source toolbox, OCTAVA (OCTA Vascular Analyzer), to automate the pre-processing, segmentation, and quantitative analysis of en face OCTA maximum intensity projection images in a standardized workflow. We present each analysis step, including optimization of filtering and choice of segmentation algorithm, and definition of metrics. We perform quantitative analysis of OCTA images from different commercial and non-commercial instruments and samples and show OCTAVA can accurately and reproducibly determine metrics for characterization of microvasculature. Wide adoption could enable studies and aggregation of data on a scale sufficient to develop reliable microvascular biomarkers for early detection, and to guide treatment, of microvascular disease., Comment: 37 pages, 9 figures

Background The RESCUE (Randomized Evaluation of Patients with Stable Angina Comparing Utilization of Noninvasive Examinations) trial was a randomized, controlled, multicenter, comparative efficacy outcomes trial designed to assess whether initial testing with coronary computed tomographic angiography (CCTA) is noninferior to single photon emission computed tomography (SPECT) myocardial perfusion imaging in directing patients with stable angina to optimal medical therapy alone or optimal medical therapy with revascularization. Methods and Results The end point was first major adverse cardiovascular event (MACE) (cardiac death or myocardial infarction), or revascularization. Noninferiority margin for CCTA was set a priori as a hazard ratio (HR) of 1.3 (95% CI=0, 1.605). One thousand fifty participants from 44 sites were randomized to CCTA (n=518) or SPECT (n=532). Mean follow‐up time was 16.2 (SD 7.9) months. There were no cardiac‐related deaths. In patients with a negative CCTA there was 1 acute myocardial infarction; in patients with a negative SPECT examination there were 2 acute myocardial infarctions; and for positive CCTA and SPECT, 1 acute myocardial infarction each. Participants in the CCTA arm had a similar rate of MACE or revascularization compared with those in the SPECT myocardial perfusion imaging arm, (HR, 1.03; 95% CI=0.61‐1.75) ( P =0.19). CCTA segment involvement by a stenosis of ≥50% diameter was a better predictor of MACE and revascularization at 1 year ( P =0.02) than the percent reversible defect size by SPECT myocardial perfusion imaging. Four (1.2%) patients with negative CCTA compared with 14 (3.2%) with negative SPECT had MACE or revascularization ( P =0.03). Conclusions There was no difference in outcomes of patients who had stable angina and who underwent CCTA in comparison to SPECT as the first imaging test directing them to optimal medical therapy alone or with revascularization. CCTA was a better predictor of MACE and revascularization. Registration Information URL: https://www.clinicaltrials.gov/ . Identifier: NCT01262625.

Background Dilated and tortuous vessels within elongated dermal papillae represent a histopathological clue of psoriasis. However, the number of dilated capillaries (capillary density) in psoriasis remains undefined as the results from the available studies differ significantly. Objectives To evaluate the capillary density in psoriasis using dermoscopy and horizontal histopathological sections (HHS), two techniques that share the horizontal view of the skin, and to compare the results with the existing data. Methods Twenty adult patients with stable plaque psoriasis were enrolled and, in each patient, a target area of the examined plaque, previously engraved by gently rotating a 5-mm biopsy punch device, underwent dermoscopy and biopsy for HHS. In all examined fields, capillary density was evaluated in a centered 4-mm diameter area, counting the number of red dots at dermoscopy and of dermal papillae at HHS. Results A total of 20 target lesions located on the trunk, arms and tights were evaluated. The mean capillary density resulting from dermoscopy was 43.02±6.60/mm 2 whereas that from HHS was 50.30±9.05/mm 2. These data showed a statistically significant difference (p = 0.006), with a strong correlation at Pearson’s test (r = 0.88). Conclusions Our results when compared with those from the existing literature showed some differences. The peculiarity of our work is represented by the precise measurement and correlation of the capillary density using two different methods, as the preliminary skin engraving allowed a perfect match between the area undergoing dermoscopy and that of skin sampling for HHS. Compared to dermoscopy in which deep-located vessels might have gone undetected, HHS seems to reflect more precisely and reliably the real capillary density showing an average of 50 capillaries/mm 2 that in a common 5x5 cm psoriatic patch corresponds to an average of 125.000 capillaries. These results highlight the extraordinary potential of psoriatic skin to develop such a complex and intricate vascular network.

Purpose We aimed to evaluate microvascular changes on optical coherence tomography angiography (OCTA) in patients with rhegmatogenous retinal detachment (RRD) who underwent silicone oil (SO) tamponade and compare changes according to macular involvement. Methods This retrospective study included 48 patients with unilateral RRD who underwent vitrectomy and SO tamponade and were stable after SO removal. Control data were obtained from the fellow healthy eye. Ophthalmic examinations, including best corrective visual acuity (BCVA) and OCTA, were conducted. Differences in vascular density (VD) in different sections of the macula and differences in the foveal avascular zone (FAZ) were analyzed between the affected eyes and control eyes. Subgroup analyses according to macular involvement were performed. Results Baseline BCVA and duration of SO tamponade were associated with postoperative BCVA (p Conclusion SO tamponade could cause microvascular changes, especially in the nasal parafoveal area. The macular-off RRD group were affected more than the macular-on RRD group.

Aim Stimulation of the nitric oxide (NO) – soluble guanylate (sGC) - protein kinase G (PKG) pathway confers protection against acute ischaemia/reperfusion injury, but more chronic effects in reducing post-myocardial infarction (MI) heart failure are less defined. The aim of this study was to not only determine whether the sGC stimulator riociguat reduces infarct size but also whether it protects against the development of post-MI heart failure. Methods and Results Mice were subjected to 30 min ischaemia via ligation of the left main coronary artery to induce MI and either placebo or riociguat (1.2 µmol/l) were given as a bolus 5 min before and 5 min after onset of reperfusion. After 24 hours, both, late gadolinium-enhanced magnetic resonance imaging (LGE-MRI) and 18F-FDG-positron emission tomography (PET) were performed to determine infarct size. In the riociguat-treated mice, the resulting infarct size was smaller (8.5±2.5% of total LV mass vs. 21.8%±1.7%. in controls, p = 0.005) and LV systolic function analysed by MRI was better preserved (60.1%±3.4% of preischaemic vs. 44.2%±3.1% in controls, p = 0.005). After 28 days, LV systolic function by echocardiography treated group was still better preserved (63.5%±3.2% vs. 48.2%±2.2% in control, p = 0.004). Conclusion Taken together, mice treated acutely at the onset of reperfusion with the sGC stimulator riociguat have smaller infarct size and better long-term preservation of LV systolic function. These findings suggest that sGC stimulation during reperfusion therapy may be a powerful therapeutic treatment strategy for preventing post-MI heart failure.

Background Neurofibromatosis type 1 (NF-1) is an autosomal dominant disease that affects one in every 3000 individuals. This disease can present a wide range of clinical manifestations, ranging from skin abnormalities to severe vascular damage. Although not commonly recognized in the context of NF-1, cerebrovascular disease (CVD), can be often present since childhood and diagnosed just later in life. When present, NF-1-associated CVD clinical manifestations may include headache, cognitive deficits and ultimately aneurysm rupture, causing death. Thus, CVD plays an important role in the clinical manifestations, disease severity and prognosis of patients with NF-1. This systematic review aims to summarize the body of evidence linking NF-1 and CVD in children. Methods Two independent investigators performed a systematic review on the PubMed and EMBASE search platforms, using the following key terms: “neurofibromatosis type 1”, “Von Recklinghausen’s disease”, "children", "adolescents", "stroke", "Moyamoya disease", "vascular diseases", "cerebrovascular disorders", "aneurysm" and "congenital abnormalities". Studies focused on assessing the development of CVD in children with NF-1 were included. Results Seven studies met the inclusion criteria. Twelve different clinical manifestations have been associated with cerebrovascular changes in children with NF-1; 44,5% of diagnosed patients were asymptomatic. Conclusion The available evidence suggests that CVDs are related with the progression of NF-1, even in the absence of a clear clinical manifestation. In addition, improved prognosis was observed when imaging tests were performed to screen for cerebrovascular alterations early during the clinical investigation. Early diagnosis of CVD in NF-1 patients foster implementation of timely interventions, directly impacting clinical outcomes.

Objective We aimed to compare the aortic valve area (AVA) calculated using fast high-resolution three-dimensional (3D) magnetic resonance (MR) image acquisition with that of the conventional two-dimensional (2D) cine MR technique. Materials and methods We included 139 consecutive patients (mean age ± standard deviation [SD], 68.5 ± 9.4 years) with aortic valvular stenosis (AS) and 21 asymptomatic controls (52.3 ± 14.2 years). High-resolution T2-prepared 3D steady-state free precession (SSFP) images (2.0 mm slice thickness, 10 contiguous slices) for 3D planimetry (3DP) were acquired with a single breath hold during mid-systole. 2D SSFP cine MR images (6.0 mm slice thickness) for 2D planimetry (2DP) were also obtained at three aortic valve levels. The calculations for the effective AVA based on the MR images were compared with the transthoracic echocardiographic (TTE) measurements using the continuity equation. Results The mean AVA ± SD derived by 3DP, 2DP, and TTE in the AS group were 0.81 ± 0.26 cm², 0.82 ± 0.34 cm², and 0.80 ± 0.26 cm², respectively (p = 0.366). The intra-observer agreement was higher for 3DP than 2DP in one observer: intraclass correlation coefficient (ICC) of 0.95 (95% confidence interval [CI], 0.94-0.97) and 0.87 (95% CI, 0.82-0.91), respectively, for observer 1 and 0.97 (95% CI, 0.96-0.98) and 0.98 (95% CI, 0.97-0.99), respectively, for observer 2. Inter-observer agreement was similar between 3DP and 2DP, with the ICC of 0.92 (95% CI, 0.89-0.94) and 0.91 (95% CI, 0.88-0.93), respectively. 3DP-derived AVA showed a slightly higher agreement with AVA measured by TTE than the 2DP-derived AVA, with the ICC of 0.87 (95% CI, 0.82-0.91) vs. 0.85 (95% CI, 0.79-0.89). Conclusion High-resolution 3D MR image acquisition, with single-breath-hold SSFP sequences, gave AVA measurement with low observer variability that correlated highly with those obtained by TTE.