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Background: Takotsubo cardiomyopathy (TTC) is a relevant differential diagnosis in patients presenting with signs of an acute coronary syndrome. Although recent literature has highlighted some salient features of this disorder, there has been little information elucidating the differences in clinical features, electrocardiographic findings, echocardiographic data and TTC-related complications associated with the different variants of TTC. Methods and results: Our institutional database constituted a collective of 114 patients diagnosed with TTC between 2003 and 2015 and these patients were subsequently divided into two groups based on the presence (n=82, 72%) or absence (n=32, 28%) of the apical form of TTC. The protocol for our proposed study was approved by the Ethics Committee of the University Medical Centre in Mannheim. It was noticed that the patients presenting with the apical form of TTC belonged to an older age group as compared to those presenting with the non-apical form (61.1±8.9 years vs. 69.5±11.2; P < 0.01). The QTc interval prolongation at index-event was observed to be quantifiably greater in the 'apical variant' patients group (484.8±57ms vs. 464±34.1 ms; P=0.06). With respect to cardiovascular risk factors, patients with arterial hypertension did have a higher predilection to present with the apical form (63.4% vs. 43.7%; P=0.06), however, the impact of smoking was less pronounced in this patient group (24.4% vs. 50%, P=0.01). Furthermore, our study highlighted a significant impact on ejection fraction (EF), with a compromised left ventricular function (3669% vs. 42.4±9.7%, P < 0.01) and greater involvement of the right ventricle in the apical variant patients group (23% vs. 3%, P=0.04). Patients with the apical form also showed a greater tendency to develop TTC-related complications such as cardiogenic shock and required longer monitoring and care in comparison. Conclusions: The apical and non-apical variants of TTC are manifestations of the same syndrome. They differ significantly, however, in their clinical presentation, related complications and prognosis. [ABSTRACT FROM AUTHOR]

Background: The arrhythmogenic potential of short QT intervals has recently been highlighted in patients with a short QT syndrome. Drug-induced QT-interval prolongation is a known risk factor for ventricular tachyarrhythmias. However, reports on drug-induced QT-interval shortening are rare and proarrhythmic effects remain unclear.Objective: Recently, rufinamide, a new antiepileptic drug for the add-on treatment of Lennox-Gastaut syndrome, was approved in the European Union and the United States. Initial trials showed drug-induced QT-interval shortening. The aim of our study was to evaluate the effects of rufinamide on QT intervals in patients with difficult-to-treat epilepsies.Methods: Nineteen consecutive patients with Lennox-Gastaut syndrome and other epilepsy syndromes were included (n = 12 men; mean age 41 ± 12 years). QRS, QT, and T(peak)-T(end) intervals were analyzed before and during rufinamide treatment.Results: The mean QT interval shortened significantly following rufinamide administration (QT interval 349 ± 23 ms vs 327 ± 17 ms; corrected QT interval 402 ± 22 ms vs 382 ± 16 ms; P = .002). T(peak)-T(end) intervals were 79 ± 17 ms before and 70 ± 20 ms on treatment (P = .07). The mean reduction of the corrected QT interval was 20 ± 18 ms. During follow-up (3.04 ± 1.09 years), no adverse events including symptomatic cardiac arrhythmias or sudden cardiac deaths were observed.Conclusion: QTc-interval shortening following oral rufinamide administration in a small patient group was not associated with significant clinical adverse effects. These observations notwithstanding, the ability of rufinamide to significantly shorten the QT interval portends a potential arrhythmogenic risk that may best be guarded against by periodic electrocardiographic recordings. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Cardiac magnetic resonance imaging (CMR) is a powerful diagnostic tool for evaluating cardiac structure and function. Recently, right ventricular wall-motion abnormalities were described using electron beam tomography in patients with Brugada syndrome. In the present study, we prospectively evaluated CMR findings in patients with Brugada syndrome compared to matched controls. METHODS AND RESULTS: CMR was performed on 20 consecutive patients with proven Brugada syndrome. The imaging protocol included breath-hold dark blood prepared T1-weighted multislice turbo spin-echo and gradient-echo images. Ventricular volumes and dimensions were compared to age- and sex-matched normal volunteers. The right ventricular outflow tract area was significantly enlarged in patients with Brugada syndrome compared to controls (11 vs 9 cm2, P = 0.018). There was a trend to larger right ventricular end-diastolic and end-systolic volumes and lower right ventricular ejection fraction in patients with Brugada syndrome compared to controls. However, none of the differences reached significance (P = 0.3, P = 0.08, and P = 0.06, respectively). There was no statistically significant difference in the left ventricular parameters between patients and controls. High intramyocardial T1 signal similar to fat signal was observed in 4 (20%) of the 20 patients compared to none of the controls. CONCLUSION: The findings support the view that subtle structural changes, such as right ventricular outflow tract dilation may point to a localized arrhythmogenic substrate in patients with Brugada syndrome. [ABSTRACT FROM AUTHOR]

An abstract of the article "Validation of the ratio of transaortic Doppler-derived peak to mean pressure gradient as a new method for assessing aortic stenosis using the Gorlin formula," by D. Haghi and colleagues is presented.

Aim: Recent research highlights the role of pericoronary adipose tissue (PCAT) in coronary artery disease (CAD) development. PCAT has been recognized as a metabolically active tissue involved in local inflammation and oxidative stress, potentially impacting CAD initiation and progression. Radiomics texture analysis shows promising results to better understand the link between PCAT quality and CAD risk. Photon-counting CT (PCCT) offers improved feature stability and holds the potential for advancing radiomics analysis in CAD research., Methods: In this retrospective, single-center, ethic committee-approved study, PCAT of the left descending artery (LAD) and right coronary artery (RCA) was manually segmented and radiomic features were extracted using pyradiomics. The study population consisted of one group of patients with CAD and plaques exclusively located in the left coronary artery and another group without CAD. Mean and standard deviation were calculated using R Statistics. Random forest feature selection was performed to identify differentiating features between the four sets CAD-LAD, CAD-RCA, non-CAD-LAD and non-CAD-RCA., Results: 36 patients were enrolled in this study (16 female, mean age 56 years). The feature "original&#95;glszm&#95;GrayLevelNonUniformity" measuring the gray-level variability was identified as the most potent differentiator between CAD-LAD and non-CAD-LAD, as well as CAD-RCA and non-CAD-RCA with the greatest differentiating capability for the LAD comparison. The feature showed little differentiating power between CAD-LAD and CAD-RCA and virtually none between non-CAD-LAD and non-CAD-RCA. The mean values were consistently lower in LAD-PCAT and exhibited patient-specific reductions in CAD patients (155.16 for CAD-LAD, 163.21 for non-CAD-LAD, 189.13 for CAD-RCA and 215.40 for non-CAD-RCA)., Conclusion: Radiomics analysis revealed differences in PCAT texture of patients with and without CAD with a potentially more homogeneous pattern in CAD-affected patients. These changes related to plaques in the left coronary artery also seemed to occur in the unaffected RCA-PCAT, although to a slightly lesser extent., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Kahmann, Nörenberg, Papavassiliu, Schoenberg, Froelich and Ayx.)

Objectives: This study aims to investigate how radiomics analysis can help understand the association between plaque texture, epicardial adipose tissue (EAT), and cardiovascular risk. Working with a Photon-counting CT, which exhibits enhanced feature stability, offers the potential to advance radiomics analysis and enable its integration into clinical routines., Methods: Coronary plaques were manually segmented in this retrospective, single-centre study and radiomic features were extracted using pyradiomics. The study population was divided into groups according to the presence of high-risk plaques (HRP), plaques with at least 50% stenosis, plaques with at least 70% stenosis, or triple-vessel disease. A combined group with patients exhibiting at least one of these risk factors was formed. Random forest feature selection identified differentiating features for the groups. EAT thickness and density were measured and compared with feature selection results., Results: A total number of 306 plaques from 61 patients (mean age 61 years +/- 8.85 [standard deviation], 13 female) were analysed. Plaques of patients with HRP features or relevant stenosis demonstrated a higher presence of texture heterogeneity through various radiomics features compared to patients with only an intermediate stenosis degree. While EAT thickness did not significantly differ, affected patients showed significantly higher mean densities in the 50%, HRP, and combined groups, and insignificantly higher densities in the 70% and triple-vessel groups., Conclusion: The combination of a higher EAT density and a more heterogeneous plaque texture might offer an additional tool in identifying patients with an elevated risk of cardiovascular events., Clinical Relevance Statement: Cardiovascular disease is the leading cause of mortality globally. Plaque composition and changes in the EAT are connected to cardiac risk. A better understanding of the interrelation of these risk indicators can lead to improved cardiac risk prediction., Key Points: Cardiac plaque composition and changes in the EAT are connected to cardiac risk. Higher EAT density and more heterogeneous plaque texture are related to traditional risk indicators. Radiomics texture analysis conducted on PCCT scans can help identify patients with elevated cardiac risk., (© 2024. The Author(s).)

Competing Interests: Declarations of interest None.

(1) Background: Epicardial adipose tissue influences cardiac biology in physiological and pathological terms. As it is suspected to be linked to coronary artery calcification, identifying improved methods of diagnostics for these patients is important. The use of radiomics and the new Photon-Counting computed tomography (PCCT) may offer a feasible step toward improved diagnostics in these patients. (2) Methods: In this retrospective single-centre study epicardial adipose tissue was segmented manually on axial unenhanced images. Patients were divided into three groups, depending on the severity of coronary artery calcification. Features were extracted using pyradiomics. Mean and standard deviation were calculated with the Pearson correlation coefficient for feature correlation. Random Forest classification was applied for feature selection and ANOVA was performed for group comparison. (3) Results: A total of 53 patients (32 male, 21 female, mean age 57, range from 21 to 80 years) were enrolled in this study and scanned on the novel PCCT. "Original&#95;glrlm&#95;LongRunEmphasis", "original&#95;glrlm&#95;RunVariance", "original&#95;glszm&#95;HighGrayLevelZoneEmphasis", and "original&#95;glszm&#95;SizeZoneNonUniformity" were found to show significant differences between patients with coronary artery calcification (Agatston score 1-99/≥100) and those without. (4) Conclusions: Four texture features of epicardial adipose tissue are associated with coronary artery calcification and may reflect inflammatory reactions of epicardial adipose tissue, offering a potential imaging biomarker for atherosclerosis detection.

Introduction: Pericoronary adipose tissue (PCAT) stands in complex bidirectional interaction with the surrounding arteries and is known to be connected to many cardiovascular diseases involving vascular inflammation. PCAT texture may be influenced by other cardiovascular risk factors such as hypercholesterolemia. The recently established photon-counting CT could improve texture analysis and help detect those changes by offering higher spatial resolution and signal-to-noise ratio., Methods: In this retrospective, single-center, IRB-approved study, PCAT of the left and right coronary artery was manually segmented and radiomic features were extracted using pyradiomics. The study population consisted of a test collective and a validation collective. The collectives were each divided into two groups defined by the presence or absence of hypercholesterolemia, taken from self-reported conditions and confirmed by medical records. Mean and standard deviation were calculated with Pearson correlation coefficient for correlation of features and visualized as boxplots and heatmaps using R statistics. Random forest feature selection was performed to identify differentiating features between the two groups. 66 patients were enrolled in this study (34 female, mean age 58 years)., Results: Two radiomics features allowing differentiation between PCAT texture of the groups were identified ( p -values between 0.013 and 0.24) and validated. Patients with hypercholesterolemia presented with a greater concentration of high-density values as indicated through analysis of specific texture features as "gldm&#95;HighGrayLevelEmphasis" (23.95 vs. 22.99) and "glrlm&#95;HighGrayLevelRunEmphasis" (24.21 vs. 23.31)., Discussion: Texture analysis of PCAT allowed differentiation between patients with and without hypercholesterolemia offering a potential imaging biomarker for this specific cardiovascular risk factor., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor JL declared a past co-authorship with the author MF., (© 2023 Kahmann, Tharmaseelan, Riffel, Overhoff, Papavassiliu, Schoenberg, Froelich and Ayx.)

Pectus excavatum (PE) is a congenital malformation with a funnel-shaped depression of the sternum that can lead to cardiac symptoms. However, there are patients with thoracic constriction (defined as elevated Haller-Index > 3.25 determined by cardiac magnetic resonance imaging (CMR)) without visible evidence of PE, leading to similar complaints. Between January 2004 till June 2020, patients who underwent CMR for further evaluation of the heart, due to cardiac symptoms were enrolled and compared to controls. Biventricular global strain analysis was assessed using feature tracking (CMR-FT). ECG and/or Holter recordings were performed to detect rhythm events. Cardiac symptoms were evaluated in detail using a questionnaire. Finally, 88 patients (male 35, female 53) with elevated Haller-Index (3.9 ± 0.8) were included and compared to CMR data from 25 individuals with confirmed PE and 25 healthy controls (HC). Mean age at time of CMR was 35 ± 16 years. The most common symptoms at presentation were palpitations (41%), followed by dyspnea (24%) and atypical chest pain (14%). Three patients (3%) had atrial fibrillation or atrial flutter. Concomitant phenomena were pericardial effusion in 39% and mitral valve prolapse (MVP) in 27% of the study cohort. While there were no differences in left ventricular function or volumes, right ventricular function (RVEF) was significantly lower in patients with internal PE compared to HC (RVEF (%) 50 ± 5 vs 59 ± 4, p < 0.01). Strain analysis revealed only discrete changes in RV strain, implying a purely mechanical problem in the absence of structural changes. RV dimensions were negatively correlated with the size of thoracic indices (r = 0.41), reflecting the extent of thoracic constriction. MVP was more prevalent in patients with greater thoracic indices (r = 0.24). The described cohort, referred to as internal PE because of the absence of external changes, showed similar CMR morphologic findings as patients with real PE (especially altered dimensions of the right heart and a lower RVEF). In addition, there was a high incidence of rhythm disturbances, such as extrasystoles or arrhythmias. In one-third of the study cohort additional abnormalities such as pericardial effusion or MVP were present, with MVP being found more frequently in patients with larger thoracic indices, suggesting a possible common pathogenesis.Trial registration: ISRCTN registry, ISRCTN15355937, retrospectively registered 03.06.2022, https://www.isrctn.com/ISRCTN15355937?q=15355937&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10 ., (© 2023. The Author(s).)

Background: We investigated the feasibility of evaluating coronary arteries with a contrast-enhanced (CE) self-navigated sparse isotropic 3D whole heart T1-weighted magnetic resonance imaging (MRI) study sequence., Methods: A total of 22 consecutive patients underwent coronary angiography and/or cardiac computed tomography (CT) including cardiac MRI. The image quality was evaluated on a 3-point Likert scale. Inter-reader variability for image quality was analyzed with Cohen's kappa for the main coronary segments (left circumflex [LCX], left anterior descending [LAD], right coronary artery [RCA]) and the left main trunk (LMT)., Results: Inter-reader agreement for image quality of the coronary tree ranged from substantial to perfect, with a Cohen's kappa of 0.722 (RCA mid ) to 1 (LCX prox ). The LMT had the best image quality. Image quality of the proximal vessel segments differed significantly from the mid- and distal segments (RCA prox vs. RCA dist , p < 0.05). The LCX segments showed no significant difference in image quality along the vessel length (LCX prox vs. LCX dist , p = n.s.). The mean acquisition time for the study sequence was 553 s (±46 s)., Conclusion: Coronary imaging with a sparse 3D whole-heart sequence is feasible in a reasonable amount of time producing good-quality imaging. Image quality was poorer in distal coronary segments and along the entire course of the LCX., (© 2022. The Author(s).)

In recent years, there has been an increasing recognition of coronary computed tomographic angiography (CCTA) and gated non-contrast cardiac CT in the workup of coronary artery disease in patients with low and intermediate pretest probability, through the readjustment guidelines by medical societies. However, in routine clinical practice, these CT data sets are usually evaluated dominantly regarding relevant coronary artery stenosis and calcification. The implementation of radiomics analysis, which provides visually elusive quantitative information from digital images, has the potential to open a new era for cardiac CT that goes far beyond mere stenosis or calcification grade estimation. This review offers an overview of the results obtained from radiomics analyses in cardiac CT, including the evaluation of coronary plaques, pericoronary adipose tissue, and the myocardium itself. It also highlights the advantages and disadvantages of use in routine clinical practice.

We hypothesized that myocardial septal scarring, assessed by cardiac magnetic resonance (CMR) using late gadolinium enhancement (LGE), at the site of cardiac contractility modulation (CCM) lead placement may predict treatment response. Eligible heart failure (HF) patients underwent LGE CMR imaging before CCM device implantation. The response to CCM therapy at follow-up was determined by a change in NYHA class and echocardiographic left ventricular ejection fraction (LVEF) assessment. Patients were classified as responders, if they showed an improvement in either NYHA class or improvement of LVEF by ≥ 5%. 58 patients were included. 67% of patients were classified as responders according to improved NYHA; 55% according to LVEF improvement. 74% of patients were responders if either NYHA class or LVEF improvement was observed. 90% of responders (according to NYHA class) showed septal LGE < 25% at septal position of the leads, while 44% of non-responders showed septal LGE > 25% (p < 0.01). In patients treated with CCM, an improvement of NYHA class was observed when leads were placed at myocardial segments with a CMR- LGE burden less than 25%., (© 2022. The Author(s).)

The aim of this paper is to evaluate the diagnostic image quality of spectral dual-source photon-counting detector coronary computed tomography angiography (PCD-CCTA) for coronary artery disease in a multicenter study. The image quality (IQ), assessability, contrast-to-noise ratio (CNR), Agatston score, and radiation exposure were measured. Stenoses were quantified and compared with invasive coronary angiography, if available. A total of 92 subjects (65% male, age 58 ± 14 years) were analyzed. The prevalence of significant coronary artery disease (CAD) (stenosis ≥ 50%) was 17% of all patients, the range of the Agatston score was 0−2965 (interquartile range (IQR) 0−135). The IQ was very good (one, IQR one−two), the CNR was very high (20 ± 10), and 5% of the segments were rated non-diagnostic. The IQ and assessability were higher in proximal coronary segments (p < 0.001). Agatston scores up to 600 did not significantly affect the assessability of the coronary segments (p = 0.3). Heart rate influenced assessability only at a high-pitch mode (p = 0.009). For the invasive coronary angiography (ICA) subgroup (n = nine), the diagnostic performance for CAD per segment was high (sensitivity 92%, specificity 96%), although the limited number of patients who underwent both diagnostic modalities limits the generalization of this finding at this stage. PCD-CCTA provides good image quality for low and moderate levels of coronary calcifications.

Aims: The aim of this study was to evaluate the prognostic value of feature tracking (FT) derived cardiac magnetic resonance (CMR) strain parameters of the left ventricle (LV)/right ventricle (RV) in ischaemic cardiomyopathy (ICM) patients treated with an implantable cardioverter-defibrillator (ICD). Current guidelines suggest a LV-ejection fraction ≤35% as major criterion for ICD implantation in ICM, but this is a poor predictor for arrhythmic events. Supplementary parameters are missing., Methods and Results: Ischaemic cardiomyopathy patients (n = 242), who underwent CMR imaging prior to primary and secondary implantation of ICD, were classified depending on EF ≤ 35% (n = 188) or >35% (n = 54). FT parameters were derived from steady-state free precession cine views using dedicated software. The primary endpoint was a composite of cardiovascular mortality (CVM) and/or appropriate ICD therapy. There were no significant differences in FT-function or LV-/RV-function parameters in patients with an EF ≤ 35% correlating to the primary endpoint. In patients with EF > 35%, standard CMR functional parameters, such as LV-EF, did not reveal significant differences. However, significant differences in most FT parameters correlating to the primary endpoint were observed in this subgroup. LV-GLS (left ventricular-global longitudinal strain) and RV-GRS (right ventricular-global radial strain) revealed the best diagnostic performance in ROC curve analysis. The combination of LV-GLS and RV-GRS showed a sensitivity of 85% and a specificity of 76% for the prediction of future events., Conclusions: The impact of FT derived measurements in the risk stratification of patients with ICM depends on LV function. The combination of LV-GLS/RV-GRS seems to be a predictor of cardiovascular mortality and/or appropriate ICD therapy in patients with EF > 35%., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Objective: This study evaluated the prognostic significance of cardiac magnetic resonance myocardial feature tracking (CMR-FT) in patients with Brugada syndrome (BrS) to detect subclinical alterations and predict major adverse events (MAE)., Methods: CMR was performed in 106 patients with BrS and 25 healthy controls. Biventricular global strain analysis was assessed using CMR-FT. Patients were followed over a median of 11.6 [8.8 ± 13.8] years., Results: The study cohort was subdivided according to the presence of a spontaneous type 1 ECG (sECG) into sBrS (BrS with sECG, n = 34 (32.1%)) and diBrS (BrS with drug-induced type 1 ECG, n = 72 (67.9%)). CMR-FT revealed morphological differences between sBrS and diBrS patients with regard to right ventricular (RV) strain (circumferential (%) (sBrS -7.9 ± 2.9 vs diBrS - 9.5 ± 3.1, p = 0.02) and radial (%) (sBrS 12.0 ± 4.3 vs diBrS 15.4 ± 5.4, p = 0.004)). During follow-up, MAE occurred in 11 patients (10.4%). Multivariable analysis was performed to identify independent predictors for the occurrence of events during follow-up. The strongest predictive value was found for RV circumferential strain (OR 3.2 (95% CI 1.4 - 6.9), p = 0.02) and RVOT/BSA (OR 3.1 (95% CI 1.0 - 7.0), p = 0.03)., Conclusions: Myocardial strain analysis detected early subclinical alterations, prior to apparent changes in myocardial function, in patients with BrS. While usual functional parameters were within the normal range, CMR-FT revealed pathological results in patients with an sECG. Moreover, RV circumferential strain and RVOT size provided additional prognostic information on the occurrence of MAE during follow-up, which reflects electrical vulnerability., Competing Interests: Conflicts of interest None of the authors has any financial interest (such as honoraria) or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript., (Copyright © 2021 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

Background: Arterial stiffness has emerged as a strong predictor of cardiovascular disease, end-organ damage and all-cause mortality. Although increased arterial stiffness has been described as a predictor of atrial fibrillation, the relationship between arterial stiffness and atrial fibrillation is uncertain., Aim: We assessed arterial stiffness in patients with atrial fibrillation compared with that in a control group., Methods: We enrolled 151 patients with atrial fibrillation who underwent pulmonary vein isolation (mean age 71.1±9.8 years) and 54 control patients with similar cardiovascular risk profiles and sinus rhythm, matched for age (mean age 68.6±15.7 years) and sex. Aortic distensibility as a measure of arterial stiffness was assessed by transoesophageal echocardiography. Patients with atrial fibrillation were followed over a median of 21 (15 to 31) months., Results: Compared with control patients, patients with atrial fibrillation had significantly lower aortic distensibility (1.8±1.1 vs. 2.1±1.1 10 -3 mmHg -1 ; P=0.02). Age (hazard ratio 0.67, 95% confidence interval 0.003 to 0.03; P=0.02) and pulse pressure (hazard ratio -1.35, 95% confidence interval -0.07 to -0.03; P<0.0001) were the strongest predictors of decreased aortic distensibility in the study cohort. This effect was independent of the type of atrial fibrillation (paroxysmal/persistent). During follow-up, decreased aortic distensibility was a predictor of cardiovascular and all-cause hospitalizations, as well as recurrences of atrial fibrillation, with a higher incidence rate of events in patients in the lowest aortic distensibility quartile (P=0.001)., Conclusions: Aortic distensibility was significantly reduced in patients with atrial fibrillation, with age and pulse pressure showing the strongest correlation, independent of the type of atrial fibrillation. Additionally, decreased aortic distensibility was associated with cardiovascular and all-cause hospitalizations, as well as recurrences of atrial fibrillation, which showed a quartile-dependent occurrence., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Only a minority of patients who receive an implantable cardioverter-defibrillator (ICD) on the basis of left ventricular ejection fraction receive appropriate ICD therapy. Peri-infarct scar zone assessed by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is a possible substrate for ventricular tachyarrhytmias (VTAs)., Objective: The aim of our prospective study was to determine whether LGE-CMR parameters can predict the occurrence of VTA in patients with ischemic cardiomyopathy (ICM)., Methods: Two hundred sixteen patients with ICM underwent CMR imaging before primary or secondary ICD implantation and were prospectively followed. We assessed CMR indices and CMR scar characteristics (infarct core and peri-infarct zone) to predict outcome and VTAs., Results: Patients were followed up for 1497 days (interquartile range 697-2237 days). Forty-seven patients (21%) received appropriate therapy during follow-up. Patients with appropriate ICD therapy had smaller core scar (31.5% ± 8.5% vs 36.8% ± 8.9%; P = .0004) but larger peri-infarct scar (12.4% ± 2.6% vs 10.5% ± 2.9%; P = .0001) than did patients without appropriate therapy. In multivariate Cox regression analysis, peri-infarct scar (hazard ratio 1.15; 95% confidence interval 1.07-1.24; P = .0001) was independently and significantly associated with VTAs whereas left ventricular ejection fraction, right ventricular ejection fraction, core scar, and left atrial ejection fraction were not., Conclusion: Scar extent of peri-infarct border zone was significantly associated with appropriate ICD therapy. Thus, LGE-CMR parameters can identify a subgroup of patients with ICM and an increased risk of life-threatening VTAs., (Copyright © 2021 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Increased arterial stiffness (AS) has been described as a predictor of atrial fibrillation (AF). This study was performed to assess whether increased AS leads to a higher symptom burden in patients with AF., Methods: One hundred sixty-two consecutive patients (104 male, 58 female) with diagnosed AF (paroxysmal or persistent) were enrolled. Symptoms most likely attributable to AF were quantified according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (SAF) scale. AS indices (aortic distensibility, cyclic circumferential strain, and aortic compliance) were characterized using transoesophageal echocardiography., Results: The cohort was divided into asymptomatic to oligosymptomatic (SAF scale 0-1, n = 78 [48.1%]) and symptomatic (SAF scale ≥ 2, n = 84 [51.9%]) patients. Symptomatic patients tended to be younger (median, 75 [interquartile range (IQR) 67-80] vs 71 [65-79]; P = 0.047) and were more likely to be female (22 [28.2%] vs 36 [42.9%]; P = 0.052). Hypertension was more frequent in symptomatic patients. Aortic compliance indices each were reduced in symptomatic patients, most pronounced for aortic compliance (median, 0.05 [IQR 0.03-0.06] vs 0.04 [0.03-0.05] cm/mm Hg; P = 0.01) followed by cyclic circumferential strain (median, 0.09 [IQR 0.07-0.11] vs 0.07 [0.04-0.10]; P = 0.02) and aortic distensibility (10 -3 mm Hg -1 , median, 1.74 [IQR 1.34-2.24] vs 1.54 [1.12-2.08]; P = 0.03). Multivariable analysis revealed aortic compliance as an independent predictor for symptoms in patients with AF with an odds ratio of 2.6 (95% confidence interval, 1.2-3.4; P = 0.003)., Conclusions: AS contributes to a high symptom burden in patients with AF, emphasizing the prognostic role of AS in the early detection and prevention in patients with AF., (Copyright © 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Fractional flow reserve based on coronary CT angiography (CT-FFR) is gaining importance for non-invasive hemodynamic assessment of coronary artery disease (CAD). We evaluated the on-site CT-FFR with a machine learning algorithm (CT-FFR ML ) for the detection of hemodynamically significant coronary artery stenosis in comparison to the invasive reference standard of instantaneous wave free ratio (iFR ® )., Methods: This study evaluated patients with CAD who had a clinically indicated coronary computed tomography angiography (cCTA) and underwent invasive coronary angiography (ICA) with iFR ® -measurements. Standard cCTA studies were acquired with third-generation dual-source computed tomography and analyzed with on-site prototype CT-FFR ML software., Results: We enrolled 40 patients (73% males, mean age 67 ± 12 years) who had iFR ® -measurement and CT-FFR ML calculation. The mean calculation time of CT-FFR ML values was 11 ± 2 min. The CT-FFR ML algorithm showed, on per-patient and per-lesion level, respectively, a sensitivity of 92% (95% CI 64-99%) and 87% (95% CI 59-98%), a specificity of 96% (95% CI 81-99%) and 95% (95% CI 84-99%), a positive predictive value of 92% (95% CI 64-99%), and 87% (95% CI 59-98%), and a negative predictive value of 96% (95% CI 81-99%) and 95% (95% CI 84-99%). The area under the receiver operating characteristic curve for CT-FFR ML on per-lesion level was 0.97 (95% CI 0.91-1.00). Per lesion, the Pearson's correlation between the CT-FFR ML and iFR ® showed a strong correlation of r = 0.82 (p < 0.0001; 95% CI 0.715-0.920)., Conclusion: On-site CT-FFR ML correlated well with the invasive reference standard of iFR ® and allowed for the non-invasive detection of hemodynamically significant coronary stenosis.

Background: Thromboembolic complications such as ischemic stroke or peripheral arterial thromboembolism are known complications in hypertrophic cardiomyopathy (HCM). We sought to assess the clinical and cardiovascular magnetic resonance (CMR) characteristics of patients with HCM suffering from thromboembolic events and analyzed the predictors of these unfavorable outcomes., Methods and results: The 115 HCM patients underwent late gadolinium enhanced (LGE) CMR and were included in the study. Follow-up was 5.6±3.6 years. The primary endpoint was the occurrence of thromboembolic events (ischemic stroke or peripheral arterial thromboembolism). It occurred in 17 (14.8%) patients (event group, EG), of whom 64.7% (11) were men. During follow-up, 10 (8.7%) patients died. Patients in the EG showed more comorbidities, such as heart failure (EG 41.2% vs. NEG (non-event group) 14.3%, P<0.01) and atrial fibrillation (AF: EG 70.6% vs. NEG 36.7%, P<0.01). Left atrial end-diastolic volume was significantly higher in the EG (EG 73±24 vs. NEG 50±33 mL/m 2 , P<0.01). Both the presence and extent of LGE were enhanced in the EG (extent% EG 23±15% vs. NEG 8±9%, P<0.0001). No patient without LGE experienced a thromboembolic event. Multivariate analysis revealed AF and LGE extent as independent predictors., Conclusions: LGE extent (>14.4%) is an independent predictor for thromboembolic complications in patients with HCM and might therefore be considered as an important risk marker. The risk for thromboembolic events is significantly elevated if accompanied by AF.

Background/aim: Despite advances in the treatment strategies of patients with atrial fibrillation (AF), the risk of AF recurrences is still over 50%. An increased left atrial volume index (LAVI) reflects left ventricular diastolic dysfunction (DD) and deterioration of the LA function. This study aims to determine AF recurrence following cardioversion (CV) or catheter ablation for AF (pulmonary vein isolation; PVI) in dependence of DD and LAVI., Patients and Methods: One hundred and sixty-two patients with paroxysmal or persistent AF in whom either CV or PVI were performed were included and followed over a mean of 22.9±3.8 months. Recurrence was defined as any recurrence of AF that occurred 3 months following the procedure. DD and LAVI were assessed using transthoracic echocardiography (TTE)., Results: Recurrent AF occurred in 100 (61.7%) patients, predominantly following CV [CV 41 (76.2%) vs. PVI 59 (54.6%), p<0.0001]. Both DD and an increased LAVI were more common in the recurrence-group [DD 46.0% vs. 14.5%, p=0.0001; LAVI (ml/m 2 ) 49.0±18.6 vs. 26.3±7.0, p<0.0001]. ROC analysis revealed LAVI>36 ml/m 2 as cut-off (p<0.0001, AUC=0.92, 95%CI=0.87-0.97, sensitivity=76%, specificity=94%). In the multivariate analysis, DD (HR=1.6, 95%CI=1.3-2.1, p=0.04) and LA enlargement (defined as LAVI>36 ml/m 2 with HR=2.1, 95%CI=1.8-2.7, p<0.0001) could be identified as independent predictors of AF recurrence after attempting to control the heart rhythm., Conclusion: LA enlargement and DD are independent risk factors associated with AF recurrence after initial successful rhythm control attempt. These findings have implications for timing of either ablation or CV., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

In postural stress, an increased preload volume leads to higher stroke volume (SV) according to the Frank-Starling law of the heart. The present study aimed to evaluate the hemodynamic response to postural stress using non-invasive inert gas rebreathing (IGR) in patients with normal as well as impaired left ventricular function. Hemodynamic measurements were performed in 91 patients undergoing cardiac magnetic resonance imaging (CMR). Mean cardiac output and SV determined by IGR were 4.4±1.3 l/min and 60±19 ml in the upright position, which increased significantly to 5.0±1.2 l/min and 75±23 ml in the supine position (P<0.01). Left ventricular systolic function was normal [ejection fraction (EF) ≥55%] in 42 patients as determined by CMR. In 21 patients, EF was mildly abnormal (45-54%), in 16 patients moderately abnormal (30-44%) and in 12 patients severely abnormal (<30%). An overall trend for a lower percentage change in SV (%ΔSV) was indicated with increasing impairment of ejection fraction. In patients with abnormal EF in comparison to those with normal EF, the %ΔSV was significantly lower (13% vs. 22%; P=0.03). Non-invasive measurement of cardiac function using IGR during postural changes may be feasible and detected significant difference in %ΔSV in patients with normal and impaired EF according to the Frank-Starling law of the heart. Several clinical scenarios including cases of heart rhythm disturbances or pulmonary or congenital heart disease are worthy of further investigation.

Myocardial T 1 -mapping, a cardiac magnetic resonance imaging technique, facilitates a quantitative measure of fibrosis which is linked to numerous cardiovascular symptoms. To overcome the problems of common techniques, including lack of accuracy and robustness against partial-voluming and heart-rate variability, we introduce a systolic saturation-recovery T 1 -mapping method. The Saturation-Pulse Prepared Heart-rate independent Inversion-Recovery (SAPPHIRE) T 1 -mapping method was modified to enable imaging during systole. Phantom measurements were used to evaluate the insensitivity of systolic T 1 -mapping towards heart-rate variability. In-vivo feasibility and accuracy were demonstrated in ten healthy volunteers with native and post-contrast T 1 -mappping during systole and diastole. To show benefits in the presence of RR-variability, six arrhythmic patients underwent native T 1 -mapping. Resulting systolic SAPPHIRE T 1 -values showed no dependence on arrhythmia in phantom (CoV < 1%). In-vivo, significantly lower T 1 (1563 ± 56 ms, precision: 84.8 ms) and ECV-values (0.20 ± 0.03) than during diastole (T 1  = 1580 ± 62 ms, p = 0.0124; precision: 60.2 ms, p = 0.03; ECV = 0.21 ± 0.03, p = 0.0098) were measured, with a strong correlation of systolic and diastolic T 1 (r = 0.89). In patients, mis-triggering-induced motion caused significant imaging artifacts in diastolic T 1 -maps, whereas systolic T 1 -maps displayed resilience to arrythmia. In conclusion, the proposed method enables saturation-recovery T 1 -mapping during systole, providing increased robustness against partial-voluming compared to diastolic imaging, for the benefit of T 1 -measurements in arrhythmic patients.

Background Left atrial function (LAF) plays an interactive role between pulmonary and systemic circulation. Cardiac biomarkers, such as amino-terminal pro-brain natriuretic peptide (NT-proBNP) and troponins, might reflect cardiac function. This study aims to evaluate the association between high sensitivity troponins (hsTn) and left atrial function in patients undergoing cardiac magnetic resonance imaging (cMRI). Methods Patients undergoing cardiac magnetic resonance imaging (cMRI) were enrolled prospectively. Patients with right ventricular dysfunction (<50%) were excluded. Blood samples for measurements of hsTn and NT-proBNP were collected at the time of cMRI. Results Eighty-four patients were included. Median LVEF was 59% (IQR 51-64%). HsTn correlated inversely with LAF within multivariable linear regression models (hsTnI: Beta -0.46; T -4.44; P = 0.0001; hsTnT: Beta -0.29; T -3.06; P = 0.003). High sensitivity troponins increased significantly according to decreasing stages of impaired LAF ( P = 0.0001). High sensitivity troponins discriminated patients with impaired LAF < 55% (hsTnT: AUC = 0.80; P = 0.0001; hsTnI: AUC = 0.74; P = 0.0001) and <45% (hsTnT: AUC = 0.75; P = 0.0001; hsTnI: AUC = 0.73; P = 0.001) and were still significantly associated in multivariable logistic regression models (LAF < 55%: hsTnT: OR = 21.78; P = 0.0001; hsTnI: OR = 5.96; P = 0.009; LAF < 45%: hsTnT: OR = 10.27; P = 0.0001; hsTnI: OR = 12.56; P = 0.001). Conclusions This study demonstrates that hsTn are able to reflect LAF being assessed by cardiac magnetic resonance imaging.

Following publication of the original article [1], the authors reported that there was a mistake in the Methods section → Measurements of biomarkers (page 6, line 3): 2000g should read 2500g. So, the correct sentence should be "All samples were obtained by venipuncture into serum monovettes ® and centrifuged at 2500g for 10 min at 20 °C."

A standardized imaging algorithm by cardiac computed tomography angiography (cCTA) (LOVE-view) was used in 30 patients to evaluate the influence of different left atrial appendage (LAA) morphologies on development of thrombosis in the LAA 6 months after implantation of an occlusion device (Watchman or Amplatzer-Cardiac-Plug) in patients with non-valvular atrial fibrillation, CHA 2 DS 2 -VASc-Score >1 and a contraindication for oral anticoagulation. The distribution of different LAA morphologies was 40% windsock, 17% broccoli and 43% chicken wing type. There was no significant difference in the level of thrombosis regarding LAA morphology or the type of chosen occlusion device. The rates of complete LAA thrombosis was 40% in broccoli type, 33% in windsock and 15% in chicken wing type. Independently of LAA type, 13% had none and 60% incomplete thrombosis. The ratio of density (LA/LAA) was 0.14 in patients with complete thrombosis and 0.67 in those with none or incomplete thrombosis. cCTA and the LOVE-view-imaging-algorithm were shown to be a valuable method for standardized imaging in clinical routine in a greater set of patients. Surprisingly thrombosis of the occluded LAA was still in progress in most cases at 6 months, whereas further studies are needed defining its clinical consequences, especially for the selection of the optimal post-procedural antithrombotic treatment strategy.

Background: Up to 40% of patients with transvenous implantable cardioverter-defibrillator (ICD) experience lead-associated complications and may suffer from high complication rates when lead extraction is indicated. Subcutaneous ICD may represent a feasible alternative; however, the efficacy of the subcutaneous ICD in the detection and treatment of ventricular arrhythmias in patients with hereditary arrhythmia syndromes has not been fully evaluated., Methods and Results: Patients with primary hereditary arrhythmia syndromes who fulfilled indication for defibrillator placement were eligible for enrollment. Between 2010 and 2016, 62 consecutive patients with primary hereditary arrhythmia syndromes, without indication for antibradycardia therapy, were enrolled in the study. Mean follow-up was 31.0±14.2 months. The study cohort comprised of 24 patients with Brugada syndrome, 17 with idiopathic ventricular fibrillation, 6 with long-QT syndrome, 1 with short-QT syndrome, 3 with catecholaminergic polymorphic ventricular tachycardia, 8 with hypertrophic cardiomyopathy, and 3 with arrhythmogenic right ventricular cardiomyopathy. Thirty-nine patients were implanted for secondary prevention. Twenty-two patients had a previous transvenous ICD implanted, but required revision because of infection or lead defects. A total of 20 spontaneous ventricular tachyarrhythmias requiring shock intervention occurred in 10 patients during follow-up. All episodes were terminated within the first ICD shock delivery with 80 J. Two patients had inappropriate therapies caused by oversensing following an uneventful implantation. No pocket-site infections and no premature revisions have occurred during follow-up., Conclusions: Our study supports the use of the subcutaneous ICD for both secondary and primary prevention of sudden cardiac death as a reliable alternative to the conventional transvenous ICD., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Purpose: This study aims to evaluate the association between high sensitivity troponins (hsTn) and mitral annular plane systolic excursion (MAPSE) in patients undergoing cardiac magnetic resonance imaging (cMRI)., Methods: Patients undergoing cMRI were prospectively enrolled. Patients with right ventricular dysfunction (< 50%) were excluded. Blood samples for measurements of hsTn and amino-terminal pro-brain natriuretic peptide (NT-proBNP) were collected at the time of cMRI., Results: 84 patients were included. Median left ventricular ejection fraction was 59% (IQR 51-64%). HsTn were correlated inversely with MAPSE within multivariable linear regression models (hsTnI: Beta - 0.19; T - 1.96; p = 0.05; hsTnT: Beta - 0.26; T - 3.26; p = 0.002). HsTn increased significantly according to decreasing stages of impaired MAPSE (p < 0.003). HsTn discriminated patients with impaired MAPSE < 11 mm (hsTnT: AUC = 0.67; p = 0.008; hsTnI: AUC = 0.64; p = 0.03) and < 8 mm (hsTnT: AUC = 0.79; p = 0.0001; hsTnI: AUC = 0.75; p = 0.001) and were still significantly associated in multivariable logistic regression models with impaired MAPSE < 11 mm (hsTnT: OR = 4.71; p = 0.002; hsTnI: OR = 4.22; p = 0.009)., Conclusions: This study demonstrates that hsTn are able to reflect MAPSE being assessed by cMRI.

Background: This study aims to evaluate the association between galectin-3 and left atrial function (LAF) in patients undergoing cMRI., Methods: Patients undergoing cMRI were prospectively enrolled. Right ventricular dysfunction (< 50%) was excluded. Blood samples for biomarker measurements of galectin-3 and NT-proBNP were collected at the time of cMRI examination., Results: A total of 84 patients were included. Median LVEF was 59% (IQR 51 - 64%). Galectin-3 was inversely correlated with overall LAF within a multivariable linear regression model (Beta -0.27; T -2.54; p = 0.01). Galectin-3 increased significantly according to the different stages of impaired LAF (p = 0.003) and was able to discriminate both patients with impaired LAF < 55% (AUC = 0.70, p = 0.002) and LAF < 45% (AUC = 0.69, p = 0.004). In multivariable logistic regression models, galectin-3 was still associated with impaired LAF (LAF < 55%: OR = 2.64, p = 0.07; LAF < 45%: OR = 6.65, p = 0.007)., Conclusions: This study demonstrates that galectin-3 is able to reflect LAF being assessed by cMRI.

Aims: Previous studies revealed that patients with Takotsubo cardiomyopathy (TTC) have a higher mortality rate than the general population. Supraventricular tachycardia is a well-known complication of TTC. This study was performed to determine the short- and long-term prognostic impact of atrial fibrillation associated with TTC patients., Methods and Results: Our institutional database constituted a collective of 114 patients diagnosed with TTC from 2003 to 2015. The patients were divided into two groups according to the presence (n = 21, 18.4%) or absence (n = 93, 81.5%) of atrial fibrillation. The endpoint was a composite of in-hospital events (thromboembolic events and life-threatening arrhythmias), all-cause mortality, rehospitalization due to heart failure, stroke, and the recurrence of TTC. The in-hospital mortality, 30-day mortality, and long-term mortality were significantly higher in the atrial fibrillation group. Kaplan-Meier analysis indicated a significantly lower event-free survival rate over a mean follow-up of 3 years in the atrial fibrillation group than that in the non-atrial fibrillation group (log-rank, P < 0.01). In a multivariate cox regression analysis, atrial fibrillation (hazard ratio, HR 2.3, 95% confidence interval, CI: 1.1-4.9, P < 0.05) and EF ≤ 35% (HR 2.0, 95% CI: 1.1-3.8, P < 0.05) were the only independent predictors of a primary endpoint., Conclusion: Rates of in-hospital events and short- as well as long-term mortality were significantly higher in TTC patients suffering from atrial fibrillation compared with patients without atrial fibrillation., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Hypertrophic cardiomyopathy (HCM) has a low risk for sudden cardiac death (SCD). The ESC clinical risk prediction model estimates the risk of SCD using clinical and echocardiographical parameters without taking into account cardiac magnetic resonance (CMR) parameters. Therefore, we compared the CMR characteristics of 149 patients with low, intermediate and high ESC risk scores. In these patients left and right ventricular ejection fraction and volumes were comparable. Patients with a high ESC risk score revealed a significantly higher extent of late gadolinium enhancement (LGE) compared to patients with intermediate or a low risk scores. During follow-up of 4 years an extent of LGE ≥20% identified patients at a higher risk for major adverse cardiac arrhythmic events in the low and intermediate ESC risk group whereas an extent of LGE <20% was associated with a low risk of major adverse cardiac arrhythmic events despite a high ESC risk score ≥6%. Hence, we hypothesize that the extent of fibrosis might be an additional risk marker.

Purpose To prospectively evaluate the accuracy of left ventricle (LV) analysis with a two-dimensional real-time cine true fast imaging with steady-state precession (trueFISP) magnetic resonance (MR) imaging sequence featuring sparse data sampling with iterative reconstruction (SSIR) performed with and without breath-hold (BH) commands at 3.0 T. Materials and Methods Ten control subjects (mean age, 35 years; range, 25-56 years) and 60 patients scheduled to undergo a routine cardiac examination that included LV analysis (mean age, 58 years; range, 20-86 years) underwent a fully sampled segmented multiple BH cine sequence (standard of reference) and a prototype undersampled SSIR sequence performed during a single BH and during free breathing (non-BH imaging). Quantitative analysis of LV function and mass was performed. Linear regression, Bland-Altman analysis, and paired t testing were performed. Results Similar to the results in control subjects, analysis of the 60 patients showed excellent correlation with the standard of reference for single-BH SSIR (r = 0.93-0.99) and non-BH SSIR (r = 0.92-0.98) for LV ejection fraction (EF), volume, and mass (P < .0001 for all). Irrespective of breath holding, LV end-diastolic mass was overestimated with SSIR (standard of reference: 163.9 g ± 58.9, single-BH SSIR: 178.5 g ± 62.0 [P < .0001], non-BH SSIR: 175.3 g ± 63.7 [P < .0001]); the other parameters were not significantly different (EF: 49.3% ± 11.9 with standard of reference, 48.8% ± 11.8 with single-BH SSIR, 48.8% ± 11 with non-BH SSIR; P = .03 and P = .12, respectively). Bland-Altman analysis showed similar measurement errors for single-BH SSIR and non-BH SSIR when compared with standard of reference measurements for EF, volume, and mass. Conclusion Assessment of LV function with SSIR at 3.0 T is noninferior to the standard of reference irrespective of BH commands. LV mass, however, is overestimated with SSIR. © RSNA, 2016 Online supplemental material is available for this article.