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Competing Interests: Conflicts of Interest None.

Background: Late gadolinium enhancement (LGE) on cardiac MRI has been shown to predict adverse outcomes in a range of cardiac diseases. However, no study has systematically reviewed and analyzed the literature across all cardiac pathologies including rare diseases., Methods: PubMed, EMBASE and Web of Science were searched for studies evaluating the relationship between LGE burden and cardiovascular outcomes. Outcomes included all-cause mortality, MACE, sudden cardiac death, sustained VT or VF, appropriate ICD shock, heart transplant, and heart failure hospitalization. Only studies reporting hazards ratios with LGE as a continuous variable were included., Results: Of the initial 8928 studies, 95 studies (23,313 patients) were included across 19 clinical entities. The studies included ischemic cardiomyopathy (7182 patients, 33 studies), hypertrophic cardiomyopathy (5080 patients, 17 studies), non-ischemic cardiomyopathy not otherwise specified (2627 patients, 11 studies), and dilated cardiomyopathy (2345 patients, 14 studies). Among 42 studies that quantified LGE by percent myocardium, a 1 % increase in LGE burden was associated with life-threatening ventricular arrhythmias (LTVA) with a pooled hazard ratio of 1.04 (CI 1.02-1.05), and MACE with a pooled hazard ratio of 1.06 (CI 1.04-1.07). The risk of these events was similar across disease types, with minimal heterogeneity., Conclusions: Despite mechanistic differences in myocardial injury, LGE appears to have a fairly consistent, dose-dependent effect on risk of LTVA, MACE, and mortality. These data can be applied to derive a patient's absolute risk of LTVA, and therefore can be clinically useful in informing decisions on primary prevention ICD implantation irrespective of the disease etiology., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Cardiac resynchronization therapy (CRT) can lead to marked symptom reduction and improved survival in selected patients with heart failure with reduced ejection fraction (HFrEF); however, many candidates for CRT based on clinical guidelines do not have a favorable response. A better way to identify patients expected to benefit from CRT that applies machine learning to accessible and cost-effective diagnostic tools such as the 12-lead electrocardiogram (ECG) could have a major impact on clinical care in HFrEF by helping providers personalize treatment strategies and avoid delays in initiation of other potentially beneficial treatments. This study addresses this need by demonstrating that a novel approach to ECG waveform analysis using functional principal component decomposition (FPCD) performs better than measures that require manual ECG analysis with the human eye and also at least as well as a previously validated but more expensive approach based on cardiac magnetic resonance (CMR). Analyses are based on five-fold cross validation of areas under the curve (AUCs) for CRT response and survival time after the CRT implant using Cox proportional hazards regression with stratification of groups using a Gaussian mixture model approach. Furthermore, FPCD and CMR predictors are shown to be independent, which demonstrates that the FPCD electrical findings and the CMR mechanical findings together provide a synergistic model for response and survival after CRT. In summary, this study provides a highly effective approach to prognostication after CRT in HFrEF using an accessible and inexpensive diagnostic test with a major expected impact on personalization of therapies., Competing Interests: Declaration of competing interest Dr. Bilchick has research grant support from Medtronic and Siemens Healthineers. Dr. Mangrum has research grant support from Boston Scientific, CardioFocus, and St. Jude Medical. Dr. Epstein has research grant support from Siemens Healthineers. Dr. Patel has a research grant from GE Healthcare and research support from Circle CVI and Neosoft., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: The declining number of electrophysiologists pursuing academic research careers could have a negative impact on innovation for patients with heart rhythm disorders in the coming decades., Objective: The objective of this study was to explore determinants of research engagement after graduation from electrophysiology (EP) fellowship programs and to evaluate associated barriers and opportunities., Methods: A mixed methods survey of EP fellows and early-career electrophysiologists was conducted, drawing from Heart Rhythm Society members. The survey encompassed 20 questions on demographics, research involvement, perceived research barriers, and perspectives on research time and opportunities. Responses were analyzed with robust Poisson regression., Results: Of 259 respondents, those with dedicated research blocks during their fellowship had a significantly higher interest in future research (relative risk, 1.15; P = .04). The number of peer-reviewed publications modestly influenced interest in continued research (relative risk, 1.0034 per publication; P < .0001), but there was no relationship to gender or race. Educational resources, networking opportunities, mentorship, funding, and protected time to enhance research engagement were important themes in the qualitative analysis, whereas key barriers to post-fellowship research were lack of mentorship, insufficient resources, and time constraints, in that order, particularly with respect to women in research. Notably, no significant differences in barriers were observed between community training programs and academic centers., Conclusion: Research experience and mentorship during EP fellowship were key determinants of subsequent research success after training, with similar findings by sex and race. These findings explain how fellowship training influences a physician's research practice after training and highlights opportunities to modify EP fellowships and to augment research retention., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

This paper presents a multimodal deep learning framework that utilizes advanced image techniques to improve the performance of clinical analysis heavily dependent on routinely acquired standard images. More specifically, we develop a joint learning network that for the first time leverages the accuracy and reproducibility of myocardial strains obtained from Displacement Encoding with Stimulated Echo (DENSE) to guide the analysis of cine cardiac magnetic resonance (CMR) imaging in late mechanical activation (LMA) detection. An image registration network is utilized to acquire the knowledge of cardiac motions, an important feature estimator of strain values, from standard cine CMRs. Our framework consists of two major components: (i) a DENSE-supervised strain network leveraging latent motion features learned from a registration network to predict myocardial strains; and (ii) a LMA network taking advantage of the predicted strain for effective LMA detection. Experimental results show that our proposed work substantially improves the performance of strain analysis and LMA detection from cine CMR images, aligning more closely with the achievements of DENSE.

Tertiary hospitals with expertise in hypertrophic cardiomyopathy (HCM) are assuming a greater role in confirming and correcting HCM diagnoses at referring centers. The objectives were to establish the frequency of alternate diagnoses from referring centers and identify predictors of accuracy of an HCM diagnosis from the referring centers. Imaging findings from echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging (CMR) in 210 patients referred to an HCM Center of Excellence between September 2020 and October 2022 were reviewed. Clinical and imaging characteristics from pre-referral studies were used to construct a model for predictors of ruling out HCM or confirming the diagnosis using machine learning methods (least absolute shrinkage and selection operator logistic regression). Alternative diagnoses were found in 38 of the 210 patients (18.1%) (median age 60 years, 50% female). A total of 17 of the 38 patients (44.7%) underwent a new CMR after their initial visit, and 14 of 38 patients (36.8%) underwent review of a previous CMR. Increased left ventricular end-diastolic volume, indexed, greater septal thickness measurements, greater left atrial size, asymmetric hypertrophy on echocardiography, and the presence of an implantable cardioverter-defibrillator were associated with higher odds ratios for confirming a diagnosis of HCM, whereas increasing age and the presence of diabetes were more predictive of rejecting a diagnosis of HCM (area under the curve 0.902, p <0.0001). In conclusion, >1 in 6 patients with presumed HCM were found to have an alternate diagnosis after review at an HCM Center of Excellence, and both clinical findings and imaging parameters predicted an alternate diagnosis., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

The aim was to test the hypothesis that left ventricular (LV) and right ventricular (RV) activation from body surface electrical mapping (CardioInsight 252-electrode vest, Medtronic) identifies optimal cardiac resynchronization therapy (CRT) pacing strategies and outcomes in 30 patients. The LV80, RV80, and BIV80 were defined as the times to 80% LV, RV, or biventricular electrical activation. Smaller differences in the LV80 and RV80 (|LV80-RV80|) with synchronized LV pacing predicted better LV function post-CRT (p = 0.0004) than the LV-paced QRS duration (p = 0.32). Likewise, a lower RV80 was associated with a better pre-CRT RV ejection fraction by CMR (r =  - 0.40, p = 0.04) and predicted post-CRT improvements in myocardial oxygen uptake (p = 0.01) better than the biventricular-paced QRS (p = 0.38), while a lower LV80 with BIV pacing predicted lower post-CRT B-type natriuretic peptide (BNP) (p = 0.02). RV pacing improved LV function with smaller |LV80-RV80| (p = 0.009). In conclusion, 3-D electrical mapping predicted favorable post-CRT outcomes and informed effective pacing strategies., (© 2023. The Author(s).)

As the mechanism for worse prognosis after cardiac resynchronization therapy (CRT) upgrades in heart failure patients with RVP dependence (RVP-HF) has clinical implications for patient selection and CRT implementation approaches, this study's objective was to evaluate prognostic implications of cardiac magnetic resonance (CMR) findings and clinical factors in 102 HF patients (23.5% female, median age 66.5 years old, median follow-up 4.8 years) with and without RVP dependence undergoing upgrade and de novo CRT implants. Compared with other CRT groups, RVP-HF patients had decreased survival ( p = 0.02), more anterior late-activated LV pacing sites ( p = 0.002) by CMR, more atrial fibrillation ( p = 0.0006), and higher creatinine (0.002). CMR activation timing at the LV pacing site predicted post-CRT LV functional improvement ( p < 0.05), and mechanical activation onset < 34 ms by CMR at the LVP site was associated with decreased post-CRT survival in a model with higher pre-CRT creatinine and B-type natriuretic peptide (AUC 0.89; p < 0.0001); however, only the higher pre-CRT creatinine partially mediated (37%) the decreased survival in RVP-HF patients. In conclusion, RVP-HF had a distinct CMR phenotype, which has important implications for the selection of LV pacing sites in CRT upgrades, and only chronic kidney disease mediated the decreased survival after CRT in RVP-HF.

Purpose: To develop a three-dimensional (two dimensions + time) convolutional neural network trained with displacement encoding with stimulated echoes (DENSE) data for displacement and strain analysis of cine MRI., Materials and Methods: In this retrospective multicenter study, a deep learning model (StrainNet) was developed to predict intramyocardial displacement from contour motion. Patients with various heart diseases and healthy controls underwent cardiac MRI examinations with DENSE between August 2008 and January 2022. Network training inputs were a time series of myocardial contours from DENSE magnitude images, and ground truth data were DENSE displacement measurements. Model performance was evaluated using pixelwise end-point error (EPE). For testing, StrainNet was applied to contour motion from cine MRI. Global and segmental circumferential strain (E cc ) derived from commercial feature tracking (FT), StrainNet, and DENSE (reference) were compared using intraclass correlation coefficients (ICCs), Pearson correlations, Bland-Altman analyses, paired t tests, and linear mixed-effects models., Results: The study included 161 patients (110 men; mean age, 61 years ± 14 [SD]), 99 healthy adults (44 men; mean age, 35 years ± 15), and 45 healthy children and adolescents (21 males; mean age, 12 years ± 3). StrainNet showed good agreement with DENSE for intramyocardial displacement, with an average EPE of 0.75 mm ± 0.35. The ICCs between StrainNet and DENSE and FT and DENSE were 0.87 and 0.72, respectively, for global E cc and 0.75 and 0.48, respectively, for segmental E cc . Bland-Altman analysis showed that StrainNet had better agreement than FT with DENSE for global and segmental E cc ., Conclusion: StrainNet outperformed FT for global and segmental E cc analysis of cine MRI. Keywords: Image Postprocessing, MR Imaging, Cardiac, Heart, Pediatrics, Technical Aspects, Technology Assessment, Strain, Deep Learning, DENSE Supplemental material is available for this article. © RSNA, 2023., Competing Interests: Disclosures of conflicts of interest: Y.W. Supported by the American Heart Association (2020AHAPRE0000203801); U.S. provisional patent applications serial numbers 63/149,900 ("System and Method for Improved Cardiac MRI Feature Tracking by Learning from Displacement-Encoded Imaging") and 63/408,760 ("Method and System for Strain Analysis that Includes CMR-trained StrainNet to Echocardiography"). C.S. U.S. provisional patent applications serial numbers 63/149,900 ("System and Method for Improved Cardiac MRI Feature Tracking by Learning from Displacement-Encoded Imaging") and 63/408,760 ("Method and System for Strain Analysis that Includes CMR-trained StrainNet to Echocardiography"). S.G. No relevant relationships. D.C.A. No relevant relationships. P.C. No relevant relationships. M.V. No relevant relationships. K.M. Co-applicant (2022) for National Health Service (NHS) Greater Glasgow and Clyde Endowment Funding (GN21CA412) for "Scar Characterisation with Cardiac MR to Predict Ventricular Arrhythmias" (£25 000); principal applicant (2021) for NHS Greater Glasgow and Clyde Endowment Funding (GN20CA408) for "Centre-specific Stress Perfusion Reference Ranges for the 3-T MRI Scanner" (£14 910); co-applicant (2021) for NHS Greater Glasgow and Clyde Endowment Funding (GN20ID164) for "CISCO-19 Visit 3" (£96 370); co-applicant (2021) for Chief Scientist Office–Long Term Effects of COVID (COV/LTE/20/10) for "Prevention and Early Treatment of COVID-19 Long Term Effects: A Randomised Clinical Trial of Resistance Exercise" (£288 660); principal applicant (2020) for Tenovus Scotland (S20-08) for "Investigating the Long-term Cardiac Sequelae of Trastuzumab Therapy" (£19 600); principal applicant (2022) for SoftMech Feasibility Funds for "Using Advanced CMR Techniques and Computational Modeling in Female Volunteers to Detect Pump Function Changes in Cancer Patients" (£10 000); principal applicant (2020) for Wellcome ISSF COVID Response Fund for "A Vascular Biology Nested Study within CISCO-19" (£10 000); co-applicant (2020) for Chief Scientist Office, Rapid Research COVID-19 for "Cardiovascular Imaging in SARS-CoV-2 (CISCO-19)" (COV/GLA/20/05) (£48, 618; MRI and CTCA scan costs in-kind); co-applicant (2020) for EPSRC Impact Acceleration Account (IAA) Cardiac Endotypes in COVID-19 for "Quantification and Mechanisms of Cardiac Injury" (£48 304) C.B. Employed by the University of Glasgow, which holds consultancy and research agreements for his work with Abbott Vascular, AstraZeneca, Auxilius Pharma, Boehringer Ingelheim, Causeway Therapeutics, Coroventis, Genenetech, GSK, HeartFlow, Menarini, Neovasc, Novartis, Siemens Healthcare, and Valo Health, with grants, contracts, consulting fees, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or education events paid to the institution, University of Glasgow; named on a pending patent for the use of zibotentan for microvascular angina, patent held by the University of Glasgow; participation on PROTECT-TAVR UK DSMB (unpaid); president of the British Society of Cardiovascular Magnetic Resonance (unpaid); past member of the Clinical Trials Committee of the Society for Cardiovascular Magnetic Resonance (SCMR) (unpaid); in-kind support for clinical research studies involving Abbott Vascular, AstraZeneca, Boehringer Ingelheim, Coroventis, GSK, HeartFlow, Novartis, and Siemens Healthcare, by contract with the University of Glasgow. C.M.H. Supported by the National Institutes of Health (NIH). L.J. No relevant relationships. B.K.F. Grant funding from the NIH (NIH DP5 OD-012132, NIH P20 GM-103527, NIH UL1 TR-000117) made to the institution where some of the cardiac MRI data was collected; full-time employment with Tempus Labs that began in late 2021 after the work was completed. J.J.C. No relevant relationships. J.C. No relevant relationships. A.D.S. The CMR Unit, Royal Brompton Hospital, receives research support from Siemens. P.F.F. Contribution to this work was funded by the British Heart Foundation (BHF), grant number RG/19/1/34160. J.N.O. No relevant relationships. D.B.E. NIH grant numbers NIH National Heart, Lung, and Blood Institute (NHLBI) R01 131975 and 131823; joint 6/8ths Stanford University/Veterans Affairs (SU/VA) appointment specified by a formal Memorandum of Understanding between SU and the VA, there is no possibility of dual compensation for the same work, no conflict of interest regarding such work, and the overall set of responsibilities meets the test of reasonableness; support for the following listed projects and proposals includes support managed through SU and through the investigator’s VA appointment, Palo Alto Veterans Institute for Research (PAVIR) and the VA Palo Alto Health Care System, primary place of performance for all is SU: "High Resolution Whole-Breast MRI at 3.0T Major," research to develop much higher resolution breast MRI, allowing better classification of small lesions to prevent unnecessary biopsy and detect cancer earlier, active support, project number R01 EB009055, source of support is IH/NIBIB, primary place of performance is SU, March 2020–November 2023, total award amount (including indirect costs) is $2 559 180; "Using Atrial Mechanics to Identify Fibrosis in Patients with Atrial Fibrillation," to use MRI of atrial mechanics to identify localized fibrosis and hypothesize that attenuated mechanics provide a robust measure of atrial fibrosis, active support, project number, source of support is NIH/NHLBI, June 2020–May 2024, total award amount (including indirect costs) is $2 787 583; "Biomechanical Optimization of Cardiac Valve Repair Operations," to validate our findings using large animal cardiac surgery models, and then hopefully translate these discoveries directly to the operating room in the human clinical arena, active support, project number R01 HL152155, source of support is NIH/NHLBI, primary place of performance is SU, May 2020–April 2024, total award amount (including indirect costs) is $2 762 997; "Advanced MR Applications Development–Tiger Team Years 13 & 14," comprises five projects in neuroimaging, high-field, pediatric, body, and musculoskeletal MRI, to advance clinical imaging capabilities, with the goals to develop and evaluate MR pulse sequences and hardware, active support, project number A117, source of support is GE Healthcare, June 2020–October 2022, total award amount (including indirect costs) is $1 936 583; "GE Healthcare–Stanford Artificial Intelligence in Medical Imaging Research," to develop methods of upstream medical imaging artificial intelligence to optimize the selection, scheduling, protocoling, and execution of exams, active support, project number A113, A114, A118, A120, source of support is GE Healthcare, July 2020–June 2024, total award amount (including indirect costs) is $3 342 138; "Abbreviated Non-Contrast-Enhanced MRI for Breast Cancer Screening," to provide accurate, low-cost, comfortable, MRI screening without intravenous contrast media, in a 10-minute exam, which will ultimately enable more effective and comfortable breast cancer screening for millions of women for whom x-ray mammography is insufficient, active support, project number R01 CA249893, source of support is NIH/NCI, primary place of performance is SU, February 2021–January 2026, total award amount (including indirect costs) is $3 127 573; "Enabling the Next Generation of High Performance Pediatric Whole-Body MR Imaging," to create and validate the next generation systems for pediatric MRI, active support, project number U01 EB029427, source of support is NIH/NIBIB, August 2020–July 2025, total award amount (including indirect costs) is $4 189 084; "Improved Diagnostic MRI Around Metallic Implants," active support, project number SPO#192723, source of support is the University of Southern California/NIH, February 2022–November 2026, total award amount (including indirect costs) is $967 045; "MR/PET Motion Correction from Coil Fingerprints," active support, project number, R01 EB029306, source of support is the NIH, September 2022–January 2024, total award amount (including indirect costs) is $1 261 824; "Developing ultra high field connectome hardware for order-of-magnitude increase in MRI sensitivity," pending support, project number SPO#280964, source of support is the NIH, primary place of performance is SU, July 1, 2023–June 30, 2028, total award amount (including indirect costs) is $4 403 210; "Fast and Accurate Cardiovascular 4D-Flow MRI for Pediatrics," pending support, project number SPO#232860, source of support is the NIH, April 1, 2023–March 31, 2028, total award amount (including indirect costs) is $3 861 471; projects managed and/or administered by PAVIR and VAPAHCS: "Using Atrial Mechanics to Identify Fibrosis in Patients with Atrial Fibrillation," to use MRI of atrial mechanics to identify localized fibrosis and hypothesize that attenuated mechanics provide a robust measure of atrial fibrosis, active support, project number R01 HL152256, source of support is NIH/NHLBI, June 2020–May 2024, total award amount (including indirect costs) is $271,187; "Implementing the Enhanced Liver Fibrosis (ELF) test to optimize prognostic screening and monitoring of hepatic fibrosis among patients at risk for non-alcoholic fatty liver disease (NAFLD)," to improve clinical care by using ELF to identify high-risk patients with hepatic fibrosis compared to standard-of-care and monitor patients for rapid disease progression or response to treatment, active support, project number C00239205, source of support is Siemens Medical Solutions USA, primary place of performance is VAPAHCS, September 2021–October 2024, total award amount (including indirect costs) is $718 147; "Abbreviated US and MRI versus FibroScan for diffuse liver disease," to improve clinical care by comparing the accuracy of vibration-controlled transient elastography (VCTE), US, and MRI for assessment of NAFLD/NASH and to introduce new US and MRI techniques to improve detection of NAFLD/NASH, active support, source of support is Siemens Medical Solutions USA, primary place of performance is VAPAHCS, September 2021–October 2024, total award amount (including indirect costs) is $551 656; author’s graduate students receive in-kind contributions. K.C.B. NHLBI grant, AHA grant, Medtronic grant, Siemens; consulting fees from Medtronic; payment or honoraria for speaker, ACC; US patent planned, issued, or pending; participation on a Data Safety Monitoring Board or Advisory Board for Left v. Left RCT funded by PCORI, 2022-present; vice-chair, HRS, research committee chair, SCMR, Clinical Trials Committee (starting in early February 2023, previously a member of the committee for several years), grant reviewer, NIH; research funding gift from Seraph Foundation. F.H.E. Research support from Siemens Healthineers Ivy Biomedical Innovation Fund; patents planned, issued, or pending, PCT/US2022/014903 Intramyocardial Tissue Displacement and Motion Measurement and Strain Analysis from MRI Cine Images Using DENSE Deep Learning; patent application number 63/408,760 entitled "Method and System for Strain Analysis that Includes CMR-trained StrainNet to Echocardiography.”, (© 2023 by the Radiological Society of North America, Inc.)

Purpose: Obstructive sleep apnea syndrome (OSAS) is an important, modifiable risk factor in the pathophysiology of arrhythmias including atrial fibrillation (AF). The purpose of the study was to evaluate cardiac electrophysiologists' (EPs) perception of OSAS., Methods: We designed a 27-item online Likert scale-based survey instrument entailing several domains: (1) relevance of OSAS in EP practice, (2) OSAS screening and diagnosis, (3) perception on treatments for OSAS, (4) opinion on the OSAS care model. The survey was distributed to 89 academic EP programs in the USA and Canada. While the survey instrument questions refer to the term sleep apnea (SA), our discussion of the diagnosis, management, and research on the sleep disorder is more accurately described with the term OSAS., Results: A total of 105 cardiac electrophysiologists from 49 institutions responded over a 9-month period. The majority of respondents agreed that sleep apnea (SA) is a major concern in their practice (94%). However, 42% reported insufficient education on SA during training. Many (58%) agreed that they would be comfortable managing SA themselves with proper training and education and 66% agreed cardiac electrophysiologists should become more involved in management. Half of EPs (53%) were not satisfied with the sleep specialist referral process. Additionally, a majority (86%) agreed that trained advanced practice providers should be able to assess and manage SA. Time constraints, lack of knowledge, and the referral process are identified as major barriers to EPs becoming more involved in SA care., Conclusions: We found that OSAS is widely recognized as a major concern for EP. However, incorporation of OSAS care in training and routine practice lags. Barriers to increased involvement include time constraints and education. This study can serve as an impetus for innovation in the cardiology OSAS care model., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: To introduce a model that describes the effects of rigid translation due to respiratory motion in displacement encoding with stimulated echoes (DENSE) and to use the model to develop a deep convolutional neural network to aid in first-order respiratory motion compensation for self-navigated free-breathing cine DENSE of the heart., Methods: The motion model includes conventional position shifts of magnetization and further describes the phase shift of the stimulated echo due to breathing. These image-domain effects correspond to linear and constant phase errors, respectively, in k-space. The model was validated using phantom experiments and Bloch-equation simulations and was used along with the simulation of respiratory motion to generate synthetic images with phase-shift artifacts to train a U-Net, DENSE-RESP-NET, to perform motion correction. DENSE-RESP-NET-corrected self-navigated free-breathing DENSE was evaluated in human subjects through comparisons with signal averaging, uncorrected self-navigated free-breathing DENSE, and breath-hold DENSE., Results: Phantom experiments and Bloch-equation simulations showed that breathing-induced constant phase errors in segmented DENSE leads to signal loss in magnitude images and phase corruption in phase images of the stimulated echo, and that these artifacts can be corrected using the known respiratory motion and the model. For self-navigated free-breathing DENSE where the respiratory motion is not known, DENSE-RESP-NET corrected the signal loss and phase-corruption artifacts and provided reliable strain measurements for systolic and diastolic parameters., Conclusion: DENSE-RESP-NET is an effective method to correct for breathing-associated constant phase errors. DENSE-RESP-NET used in concert with self-navigation methods provides reliable free-breathing DENSE myocardial strain measurement., (© 2023 The Authors. Magnetic Resonance in Medicine published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Automated identification of myocardial scar from late gadolinium enhancement cardiac magnetic resonance images (LGE-CMR) is limited by image noise and artifacts such as those related to motion and partial volume effect. This paper presents a novel joint deep learning (JDL) framework that improves such tasks by utilizing simultaneously learned myocardium segmentations to eliminate negative effects from non-region-of-interest areas. In contrast to previous approaches treating scar detection and myocardium segmentation as separate or parallel tasks, our proposed method introduces a message passing module where the information of myocardium segmentation is directly passed to guide scar detectors. This newly designed network will efficiently exploit joint information from the two related tasks and use all available sources of myocardium segmentation to benefit scar identification. We demonstrate the effectiveness of JDL on LGE-CMR images for automated left ventricular (LV) scar detection, with great potential to improve risk prediction in patients with both ischemic and non-ischemic heart disease and to improve response rates to cardiac resynchronization therapy (CRT) for heart failure patients. Experimental results show that our proposed approach outperforms multiple state-of-the-art methods, including commonly used two-step segmentation-classification networks, and multitask learning schemes where subtasks are indirectly interacted.

Study Objective: To identify Change in Systemic Arterial Pulsatitlity index (ΔSAPi) as a novel hemodynamic marker associated with outcomes in heart failure (HF)., Design: The ESCAPE trial was a randomized controlled trial., Setting: The ESCAPE trial was conducted at 26 sites., Participants: 134 patients were analyzed (mean age 56.8 ± 13.4 years, 29% female)., Interventions: We evaluated the change in SAPi, ([systemic pulse pressure/pulmonary artery wedge pressure) obtained at baseline and at the final hemodynamic measurement in the ESCAPE trial., Main Outcome Measures: Change in SAPi, (ΔSAPi), was analyzed for the primary outcomes of death, heart transplant, left ventricular assist device (DTxLVAD) or hospitalization, (DTxLVADHF) and secondary outcome of DTxLVAD using Cox proportional hazards regression., Results: Median change in SAPi was 0.81 (IQR 0.20-1.68). ΔSAPi in uppermost quartile was associated with reductions in DTxLVADHF (HR 0.55 [95% CI 0.32, 0.93]). ΔSAPi in the uppermost and lowermost quartiles combined was similarly associated with significant reductions in DTxLVADHF (HR 0.62 [95% CI 0.41, 0.94]). ΔSAPi higher than 1.17 was associated with improved DTxLVADHF. ΔSAPi was also associated with troponin levels at discharge (regression coefficient p = 0.001) and trended with 6-minute walk at discharge (Spearman correlation r = 0.179, p = 0.058)., Conclusion: ΔSAPi was strongly associated with improved HF clinical profile and adverse outcomes. These findings support further exploration of Δ SAPi in the risk stratification of HF., Competing Interests: Disclosure Statement: The authors declare that there is no conflict of interest.

There are many challenges in the current landscape of electrophysiology (EP) clinical and translational research, including increasing costs and complexity, competing demands, regulatory requirements, and challenges with study implementation. This review seeks to broadly discuss the state of EP research, including challenges and opportunities. Included here are results from a Heart Rhythm Society (HRS) Research Committee member survey detailing HRS members' perspectives regarding both barriers to clinical and translational research and opportunities to address these challenges. We also provide stakeholder perspectives on barriers and opportunities for future EP research, including input from representatives of the U.S. Food and Drug Administration, industry, and research funding institutions that participated in a Research Collaboratory Summit convened by HRS. This review further summarizes the experiences of the heart failure and heart valve communities and how they have approached similar challenges in their own fields. We then explore potential solutions, including various models of research ecosystems designed to identify research challenges and to coordinate ways to address them in a collaborative fashion in order to optimize innovation, increase efficiency of evidence generation, and advance the development of new therapeutic products. The objectives of the proposed collaborative cardiac EP research community are to encourage and support scientific discourse, research efficiency, and evidence generation by exploring collaborative and equitable solutions in which stakeholders within the EP community can interact to address knowledge gaps, innovate, and advance new therapies., (Copyright © 2022 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: A screening tool to predict response to cardiac resynchronization therapy (CRT) could improve patient selection and outcomes., Objective: The purpose of this study was to investigate the feasibility and safety of noninvasive CRT via transcutaneous ultrasonic left ventricular (LV) pacing applied as a screening test before CRT implants., Methods: P-wave-triggered ultrasound stimuli were delivered during bolus dosing of an echocardiographic contrast agent to simulate CRT noninvasively. Ultrasound pacing was delivered at a variety of LV locations with a range of atrioventricular delays to achieve fusion with intrinsic ventricular activation. Three-dimensional cardiac activation maps were acquired via the Medtronic CardioInsight 252-electrode mapping vest during baseline, ultrasound pacing, and after CRT implantation. A separate control group received only the CRT implants., Results: Ultrasound pacing was achieved in 10 patients with a mean of 81.2 ± 50.8 ultrasound paced beats per patient and up to 20 consecutive beats of ultrasound pacing. QRS width at baseline (168.2 ± 17.8 ms) decreased significantly to 117.3 ± 21.5 ms ( P  <.001) in the best ultrasound paced beat and to 125.8 ± 13.3 ms ( P <.001) in the best CRT beat. Electrical activation patterns were similar between CRT pacing and ultrasound pacing with stimulation from the same area of the LV. Troponin results were similar between the ultrasound pacing and the control groups ( P = .96), confirming safety., Conclusion: Noninvasive ultrasound pacing before CRT is safe and feasible, and it estimates the degree of electrical resynchronization achievable with CRT. Further study of this promising technique to guide CRT patient selection is warranted., (© 2022 Heart Rhythm Society. Published by Elsevier Inc.)

Background and Aims: Invasive hemodynamics may provide a more nuanced assessment of cardiac function and risk phenotyping in patients undergoing cardiac surgery. The systemic pulse pressure (SPP) to central venous pressure (CVP) ratio represents an integrated index of right and left ventricular function and thus may demonstrate an association with valvular heart surgery outcomes. This study hypothesized that a low SPP/CVP ratio would be associated with mortality in valvular surgery patients., Methods: This retrospective cohort study examined adult valvular surgery patients with preoperative right heart catheterization from 2007 through 2016 at a single tertiary medical center (n = 215). Associations between the SPP/CVP ratio and mortality were investigated with univariate and multivariate analyses., Results: Among 215 patients (age 69.7 ± 12.4 years; 55.8% male), 61 died (28.4%) over a median follow-up of 5.9 years. A SPP/CVP ratio <7.6 was associated with increased mortality (relative risk 1.70, 95% confidence interval [CI] 1.08-2.67, p = .019) and increased length of stay (11.56 ± 13.73 days vs. 7.93 ± 4.92 days, p = .016). It remained an independent predictor of mortality (adjusted odds ratio 3.99, 95% CI 1.47-11.45, p = .008) after adjusting for CVP, mean pulmonary artery pressure, aortic stenosis, tricuspid regurgitation, smoking status, diabetes mellitus, dialysis, and cross-clamp time., Conclusions: A low SPP/CVP ratio was associated with worse outcomes in patients undergoing valvular heart surgery. This metric has potential utility in preoperative risk stratification to guide patient selection, prognosis, and surgical outcomes., (© 2022 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals LLC.)

Ventriculo-arterial (VA) coupling has been shown to have physiologic importance in heart failure (HF). We hypothesized that the systemic arterial pulsatility index (SAPi), a measure that integrates pulse pressure and a proxy for left ventricular end-diastolic pressure, would be associated with adverse outcomes in advanced HF. We evaluated the SAPi ([systemic systolic blood pressure-systemic diastolic blood pressure]/pulmonary artery wedge pressure) obtained from the final hemodynamic measurement in patients randomized to therapy guided by a pulmonary arterial catheter (PAC) and with complete data in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. Cox proportional hazards regression was performed for the outcomes of (a) death, transplant, left ventricular assist device (DTxLVAD) or hospitalization, (DTxLVADHF) and (b) DTxLVAD. Among 142 patients (mean age 56.8 ± 13.3 years, 30.3% female), the median SAPi was 2.57 (IQR 1.63-3.45). Increasing SAPi was associated with significant reductions in DTxLVAD (HR 0.60 per unit increase in SAPi, 95% CI 0.44-0.84) and DTxLVADHF (HR 0.81 per unit increase, 95% CI 0.70-0.95). Patients with a SAPi ≤ 2.57 had a marked increase in both outcomes, including more than twice the risk of DTxLVAD (HR 2.19, 95% CI 1.11-4.30) over 6 months. Among advanced heart failure patients with invasive hemodynamic monitoring in the ESCAPE trial, SAPi was strongly associated with adverse clinical outcomes. These findings support further investigation of the SAPi to guide treatment and prognosis in HF undergoing invasive hemodynamic monitoring., (© 2022. Springer Japan KK, part of Springer Nature.)

Background: The implications of coronavirus disease 2019 (COVID-19) infection on outcomes after invasive therapeutic strategies among patients presenting with acute myocardial infarction (AMI) are not well studied., Hypothesis: To assess the outcomes of COVID-19 patients presenting with AMI undergoing an early invasive treatment strategy., Methods: This study was a cross-sectional, retrospective analysis of the National COVID Cohort Collaborative database including all patients presenting with a recorded diagnosis of AMI (ST-elevation myocardial infarction (MI) and non-ST elevation MI). COVID-19 positive patients with AMI were stratified into one of four groups: (1a) patients who had a coronary angiogram with percutaneous coronary intervention (PCI) within 3 days of their AMI; (1b) PCI within 3 days of AMI with coronary artery bypass graft (CABG) within 30 days; (2a) coronary angiogram without PCI and without CABG within 30 days; and (2b) coronary angiogram with CABG within 30 days. The main outcomes were respiratory failure, cardiogenic shock, prolonged length of stay, rehospitalization, and death., Results: There were 10 506 COVID-19 positive patients with a diagnosis of AMI. COVID-19 positive patients with PCI had 8.2 times higher odds of respiratory failure than COVID-19 negative patients (p = .001). The odds of prolonged length of stay were 1.7 times higher in COVID-19 patients who underwent PCI (p = .024) and 1.9 times higher in patients who underwent coronary angiogram followed by CABG (p = .001)., Conclusion: These data demonstrate that COVID-19 positive patients with AMI undergoing early invasive coronary angiography had worse outcomes than COVID-19 negative patients., (© 2022 The Authors. Clinical Cardiology published by Wiley Periodicals, LLC.)

Background: Mechanisms of sex-based differences in outcomes following cardiac resynchronization therapy (CRT) are poorly understood., Objective: To use cardiac magnetic resonance (CMR) to define mechanisms of sex-based differences in outcomes after CRT and describe distinct CMR-based phenotypes of CRT candidates based on sex and non-ischemic/ischemic cardiomyopathy type., Materials and Methods: In a prospective study, sex-based differences in three short-term CRT response measures [fractional change in left ventricular end-systolic volume index 6 months after CRT (LVESVI-FC), B-type natriuretic peptide (BNP) 6 months after CRT, change in peak VO 2 6 months after CRT], and long-term survival were evaluated with respect to 39 baseline parameters from CMR, exercise testing, laboratory testing, electrocardiograms, comorbid conditions, and other sources. CMR was also used to quantify the degree of left-ventricular mechanical dyssynchrony by deriving the circumferential uniformity ratio estimate (CURE-SVD) parameter from displacement encoding with stimulated echoes (DENSE) strain imaging. Statistical methods included multivariable linear regression with evaluation of interaction effects associated with sex and cardiomyopathy type (ischemic and non-ischemic cardiomyopathy) and survival analysis., Results: Among 200 patients, the 54 female patients (27%) pre-CRT had a smaller CMR-based LVEDVI ( p = 0.04), more mechanical dyssynchrony based on the validated CMR CURE-SVD parameter ( p = 0.04), a lower frequency of both late gadolinium enhancement (LGE) and ischemic cardiomyopathy ( p < 0.0001), a greater RVEF ( p = 0.02), and a greater frequency of LBBB ( p = 0.01). After categorization of patients into four groups based on cardiomyopathy type (ischemic/non-ischemic cardiomyopathy) and sex, female patients with non-ischemic cardiomyopathy had the lowest CURE-SVD ( p = 0.003), the lowest pre-CRT BNP levels ( p = 0.01), the lowest post-CRT BNP levels ( p = 0.05), and the most favorable LVESVI-FC ( p = 0.001). Overall, female patients had better 3-year survival before adjustment for cardiomyopathy type ( p = 0.007, HR = 0.45) and after adjustment for cardiomyopathy type ( p = 0.009, HR = 0.67)., Conclusion: CMR identifies distinct phenotypes of female CRT patients with non-ischemic and ischemic cardiomyopathy relative to male patients stratified by cardiomyopathy type. The more favorable short-term response and long-term survival outcomes in female heart failure patients with CRT were associated with lower indexed CMR-based LV volumes, decreased presence of scar associated with prior myocardial infarction and ICM, and greater CMR-based dyssynchrony with the CURE-SVD., 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., (Copyright © 2022 Bivona, Tallavajhala, Abdi, Oomen, Gao, Malhotra, Darby, Monfredi, Mangrum, Mason, Mazimba, Salerno, Kramer, Epstein, Holmes and Bilchick.)

Purpose: The synergistic use of k-t undersampling and multiband (MB) imaging has the potential to provide extended slice coverage and high spatial resolution for first-pass perfusion MRI. The low-rank plus sparse (L + S) model has shown excellent performance for accelerating single-band (SB) perfusion MRI., Methods: A MB data consistency method employing ESPIRiT maps and through-plane coil information was developed. This data consistency method was combined with the temporal L + S constraint to form the slice-L + S method. Slice-L + S was compared to SB L + S and the sequential operations of split slice-GRAPPA and SB L + S (seq-SG-L + S) using synthetic data formed from multislice SB images. Prospectively k-t undersampled MB data were also acquired and reconstructed using seq-SG-L + S and slice-L + S., Results: Using synthetic data with total acceleration rates of 6-12, slice-L + S outperformed SB L + S and seq-SG-L + S (N = 7 subjects) with respect to normalized RMSE and the structural similarity index (P < 0.05 for both). For the specific case with MB factor = 3 and rate 3 undersampling, or for SB imaging with rate 9 undersampling (N = 7 subjects), the normalized RMSE values were 0.037 ± 0.007, 0.042 ± 0.005, and 0.031 ± 0.004; and the structural similarity index values were 0.88 ± 0.03, 0.85 ± 0.03, and 0.89 ± 0.02 for SB L + S, seq-SG-L + S, and slice-L + S, respectively (P < 0.05 for both). For prospectively undersampled MB data, slice-L + S provided better image quality than seq-SG-L + S for rate 6 (N = 7) and rate 9 acceleration (N = 7) as scored by blinded experts., Conclusion: Slice-L + S outperformed SB-L + S and seq-SG-L + S and provides 9 slice coverage of the left ventricle with a spatial resolution of 1.5 mm × 1.5 mm with good image quality., (© 2022 The Authors. Magnetic Resonance in Medicine published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Background As patients derive variable benefit from generator changes (GCs) of implantable cardioverter-defibrillators (ICDs) with an original primary prevention (PP) indication, better predictors of outcomes are needed. Methods and Results In the National Cardiovascular Data Registry ICD Registry, patients undergoing GCs of initial non-cardiac resynchronization therapy PP ICDs in 2012 to 2016, predictors of post-GC survival and survival benefit versus control heart failure patients without ICDs were assessed. These included predicted annual mortality based on the Seattle Heart Failure Model, left ventricular ejection fraction (LVEF) >35%, and the probability that a patient's death would be arrhythmic (proportional risk of arrhythmic death [PRAD]). In 40 933 patients undergoing GCs of initial noncardiac resynchronization therapy PP ICDs (age 67.7±12.0 years, 24.5% women, 34.1% with LVEF >35%), Seattle Heart Failure Model-predicted annual mortality had the greatest effect size for decreased post-GC survival ( P <0.0001). Patients undergoing GCs of initial noncardiac resynchronization therapy PP ICDs with LVEF >35% had a lower Seattle Heart Failure Model-adjusted survival versus 23 472 control heart failure patients without ICDs (model interaction hazard ratio, 1.21 [95% CI, 1.11-1.31]). In patients undergoing GCs of initial noncardiac resynchonization therapy PP ICDs with LVEF ≤35%, the model indicated worse survival versus controls in the 21% of patients with a PRAD <43% and improved survival in the 10% with PRAD >65%. The association of the PRAD with survival benefit or harm was similar in patients with or without pre-GC ICD therapies. Conclusions Patients who received replacement of an ICD originally implanted for primary prevention and had at the time of GC either LVEF >35% alone or both LVEF ≤35% and PRAD <43% had worse survival versus controls without ICDs.

Background: Gout is a common comorbidity in heart failure (HF) patients and is frequently associated with acute exacerbations during treatment for decompensated HF. Although colchicine is often used to manage acute gout in HF patients, its impact on clinical outcomes when used during acute decompensated HF is unknown., Methods: This was a single center, retrospective study of hospitalized patients treated for an acute HF exacerbation with and without acute gout flare between March 2011 and December 2020. We assessed clinical outcomes in patients treated with colchicine for a gout flare compared to those who did not experience a gout flare or receive colchicine. The primary outcome was in-hospital all-cause mortality., Results: Among 1047 patient encounters for acute HF during the study period, there were 237 encounters (22.7%) where the patient also received colchicine for acute gout during admission. In-hospital all-cause mortality was significantly reduced in the colchicine group compared with the control group (2.1% vs. 6.5%, p = .009). The colchicine group had increased length of stay (9.93 vs. 7.96 days, p < .001) but no significant difference in 30-day readmissions (21.5% vs. 19.5%, p = .495). In a Cox proportional hazards model adjusted for age, inpatient colchicine use was associated with improved survival to discharge (hazards ratio [HR] 0.163, 95% confidence interval [CI] 0.051-0.525, p = .002) and a reduced rate of in-hospital CV mortality (HR 0.184, 95% CI 0.044-0.770, p = .021)., Conclusion: Among patients with a HF exacerbation, treatment with colchicine for a gout flare was associated with significantly lower in-hospital mortality compared with those not treated for acute gout., (© 2022 The Authors. Clinical Cardiology published by Wiley Periodicals, LLC.)

Background: Cardiac resynchronization therapy (CRT) response is complex, and better approaches are required to predict survival and need for advanced therapies., Objective: The objective was to use machine learning to characterize multidimensional CRT response and its relationship with long-term survival., Methods: Associations of 39 baseline features (including cardiac magnetic resonance [CMR] findings and clinical parameters such as glomerular filtration rate [GFR]) with a multidimensional CRT response vector (consisting of post-CRT left ventricular end-systolic volume index [LVESVI] fractional change, post-CRT B-type natriuretic peptide, and change in peak VO 2 ) were evaluated. Machine learning generated response clusters, and cross-validation assessed associations of clusters with 4-year survival., Results: Among 200 patients (median age 67.4 years, 27.0% women) with CRT and CMR, associations with more than 1 response parameter were noted for the CMR CURE-SVD dyssynchrony parameter (associated with post-CRT brain natriuretic peptide [BNP] and LVESVI fractional change) and GFR (associated with peak VO 2 and post-CRT BNP). Machine learning defined 3 response clusters: cluster 1 (n = 123, 90.2% survival [best]), cluster 2 (n = 45, 60.0% survival [intermediate]), and cluster 3 (n = 32, 34.4% survival [worst]). Adding the 6-month response cluster to baseline features improved the area under the receiver operating characteristic curve for 4-year survival from 0.78 to 0.86 ( P = .02). A web-based application was developed for cluster determination in future patients., Conclusion: Machine learning characterizes distinct CRT response clusters influenced by CMR features, kidney function, and other factors. These clusters have a strong and additive influence on long-term survival relative to baseline features., (© 2022 Heart Rhythm Society. Published by Elsevier Inc.)

Background: While multiple cardiovascular magnetic resonance (CMR) methods provide excellent reproducibility of global circumferential and global longitudinal strain, achieving highly reproducible segmental strain is more challenging. Previous single-center studies have demonstrated excellent reproducibility of displacement encoding with stimulated echoes (DENSE) segmental circumferential strain. The present study evaluated the reproducibility of DENSE for measurement of whole-slice or global circumferential (E cc ), longitudinal (E ll ) and radial (E rr ) strain, torsion, and segmental E cc at multiple centers., Methods: Six centers participated and a total of 81 subjects were studied, including 60 healthy subjects and 21 patients with various types of heart disease. CMR utilized 3 T scanners, and cine DENSE images were acquired in three short-axis planes and in the four-chamber long-axis view. During one imaging session, each subject underwent two separate DENSE scans to assess inter-scan reproducibility. Each subject was taken out of the scanner and repositioned between the scans. Intra-user, inter-user-same-site, inter-user-different-site, and inter-user-Human-Deep-Learning (DL) comparisons assessed the reproducibility of different users analyzing the same data. Inter-scan comparisons assessed the reproducibility of DENSE from scan to scan. The reproducibility of whole-slice or global E cc , E ll and E rr , torsion, and segmental E cc were quantified using Bland-Altman analysis, the coefficient of variation (CV), and the intraclass correlation coefficient (ICC). CV was considered excellent for CV ≤ 10%, good for 10% < CV ≤ 20%, fair for 20% < CV ≤ 40%, and poor for CV > 40. ICC values were considered excellent for ICC > 0.74, good for ICC 0.6 < ICC ≤ 0.74, fair for ICC 0.4 < ICC ≤ 0.59, poor for ICC < 0.4., Results: Based on CV and ICC, segmental E cc provided excellent intra-user, inter-user-same-site, inter-user-different-site, inter-user-Human-DL reproducibility and good-excellent inter-scan reproducibility. Whole-slice E cc and global E ll provided excellent intra-user, inter-user-same-site, inter-user-different-site, inter-user-Human-DL and inter-scan reproducibility. The reproducibility of torsion was good-excellent for all comparisons. For whole-slice E rr , CV was in the fair-good range, and ICC was in the good-excellent range., Conclusions: Multicenter data show that 3 T CMR DENSE provides highly reproducible whole-slice and segmental E cc , global E ll , and torsion measurements in healthy subjects and heart disease patients., (© 2022. The Author(s).)

Background: Structural remodeling in chronic systolic heart failure (HF) is associated with neurohormonal and hemodynamic perturbations among HF patients presenting with cardiogenic shock (CS) and HF. Our objective was to test the hypothesis was that atrial remodeling marked by an increased right atrial volume index (RAVI) to left atrial volume index (LAVI) ratio is associated with adverse clinical outcomes in CS., Methods: Patients in this cohort were admitted to the intensive care unit with evidence of congestion (pulmonary capillary wedge pressure > 15) and cardiogenic shock (cardiac index < 2.2, systolic blood pressure < 90 mmHg, and clinical evidence supporting CS) and had an echocardiogram at the time of admission. RAVI was measured using Simpson's method in the apical four-chamber view, while LAVI was measured using the biplane disc summation method in the four and two-chamber views by two independent observers. Cox proportional hazards regression analysis was used to assess the association of RAVI-LAVI with the combined outcome of death or left ventricular assist device (LVAD)., Results: Among 113 patients (mean age 59 ± 14.9 years, 29.2% female), median RAVI/LAVI was 0.84. During a median follow-up of 12 months, 43 patients died, and 65 patients had the combined outcomes of death or LVAD. Patients with RAVI/LAVI ratio above the median had a greater incidence of death or LVAD (Log-rank p ≤ 0.001), and increasing RAVI/LAVI was significantly associated with the outcomes of death or LVAD (HR 1.71 95% CI 1.11-2.64, chi square 5.91, p = 0.010) even after adjustment for patient characteristics, echocardiographic and hemodynamic variables., Conclusion: RAVI/LAVI is an easily assessed novel echocardiographic parameter strongly associated with the survival and or the need for mechanical circulatory support in patients with CS., (© 2021. Japanese Society of Echocardiography.)

Cardiac resynchronization therapy (CRT) is an effective therapy for patients who suffer from heart failure and ventricular dyssynchrony such as left bundle branch block (LBBB). When it works, it reverses adverse left ventricular (LV) remodeling and the progression of heart failure. However, CRT response rate is currently as low as 50-65%. In theory, CRT outcome could be improved by allowing clinicians to tailor the therapy through patient-specific lead locations, timing, and/or pacing protocol. However, this also presents a dilemma: there are far too many possible strategies to test during the implantation surgery. Computational models could address this dilemma by predicting remodeling outcomes for each patient before the surgery takes place. Therefore, the goal of this study was to develop a rapid computational model to predict reverse LV remodeling following CRT. We adapted our recently developed computational model of LV remodeling to simulate the mechanics of ventricular dyssynchrony and added a rapid electrical model to predict electrical activation timing. The model was calibrated to quantitatively match changes in hemodynamics and global and local LV wall mass from a canine study of LBBB and CRT. The calibrated model was used to investigate the influence of LV lead location and ischemia on CRT remodeling outcome. Our model results suggest that remodeling outcome varies with both lead location and ischemia location, and does not always correlate with short-term improvement in QRS duration. The results and time frame required to customize and run this model suggest promise for this approach in a clinical setting., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Left and right atrial volume indices (LAVI and RAVI) are markers of cardiac remodeling. LAVI and RAVI are associated with worse outcomes in other cardiac conditions. This study aimed to determine the associations of these atrial volume indices with survival time post-cardiac arrest., Methods: This was a single center, retrospective study of patients with a sudden cardiac arrest event during index hospitalization from 2014-2018 based on pre-arrest parameters. The analysis was stratified based on whether a pulseless ventricular tachycardia/ventricular fibrillation (pVT/VF) event or a pulseless electrical activity (PEA)/asystole event occurred. Cox proportional hazards regression and model selection with best subsets approach evaluated the association of atrial volume parameters with survival times in the context of other covariates., Results: Of 305 patients studied (64 ± 14 years, 37% female), the mean LAVI was 34.0 ± 15.8 mL/m 2 (based on 162 reliable measurements), and mean RAVI was 25.0 ± 15.6 mL/m 2 (based on 163 measurements). Increased atrial volume indices were most strongly associated with survival in patients who had sustained pVT/VF (LAVI HR 0.47, 95% CI 0.25-0.90, p = 0.020; RAVI HR 0.57, 95% CI 0.30-1.05, p = 0.074). In multivariable best subsets Cox regression with LAVI, RAVI, and 13 other scaled covariates, LAVI < 34 ml/m 2 was by far the best single predictor of survival (p < 0.0001), and the next best predictor was the absence of pulmonary hypertension., Conclusion: Among patients with cardiac arrest from ventricular arrhythmias, those with no more than mild left atrial enlargement pre-arrest by LAVI measurement had the best prognosis. Additional studies are indicated to validate the importance of this finding for clinical management decisions., Condensed Abstract: In patients with sudden cardiac arrest associated with ventricular arrhythmias, a left atrial volume index (LAVI) < 34 mL/m 2 prior to the arrest had the strongest association with survival among fifteen candidate predictors. Pulmonary hypertension was more common in patients with an elevated right atrial volume index (RAVI), and the absence of pulmonary hypertension was the next best pre-arrest parameter predictive of survival. Larger studies are indicated to validate the use of LAVI for clinical management decisions in this condition., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: The prognostic importance of trajectories of neurohormones relative to left ventricular function over time in heart failure with reduced and mid-range EF (HFrEF and HFmrEF) is poorly defined., Objective: To evaluate left ventricular ejection fraction (LVEF) and B-type natriuretic peptide (BNP) trajectories in HFrEF and HFmrEF., Methods: Analyses of LVEF and BNP trajectories after incident HF admissions presenting with abnormal LV systolic function were performed using 3 methods: a Cox proportional hazards model with time-varying covariates, a dual longitudinal-survival model with shared random effects, and an unsupervised analysis to capture 3 discrete trajectories for each parameter., Results: Among 1,158 patients (68.9 ± 13.0 years, 53.3% female), both time-varying LVEF measurements (P=.001) and log-transformed BNP measurements (p-values=2 × 10 -16 ) were independently associated with survival during 6 years after covariate adjustment. In the dual longitudinal/survival model, both LVEF and BNP trajectories again were independently associated with survival (P<.0001 in each model); however, LVEF was more dynamic than BNP (P <.0001 for time covariate in LVEF longitudinal model versus P=.88 for the time covariate in BNP longitudinal model). In the unsupervised analysis, 3 discrete LVEF trajectories (dividing the cohort into approximately thirds) and 3 discrete BNP trajectories were identified. Discrete LVEF and BNP trajectories had independent prognostic value in Kaplan-Meier analyses (P<.0001), and substantial membership variability across BNP and LVEF trajectories was noted., Conclusion: Although LVEF trajectories have greater temporal variation, BNP trajectories provide additive prognostication and an even stronger association with survival times in heart failure patients with abnormal LV systolic function., (Copyright © 2021. Published by Elsevier Inc.)

Objectives: The objective was to determine the feasibility and effectiveness of cardiac magnetic resonance (CMR) cine and strain imaging before and after cardiac resynchronization therapy (CRT) for assessment of response and the optimal resynchronization pacing strategy., Background: CMR with cardiac implantable electronic devices can safely provide high-quality right ventricular/left ventricular (LV) ejection fraction (RVEF/LVEF) assessments and strain., Methods: CMR with cine imaging, displacement encoding with stimulated echoes for the circumferential uniformity ratio estimate with singular value decomposition (CURE-SVD) dyssynchrony parameter, and scar assessment was performed before and after CRT. Whereas the pre-CRT scan constituted a single "imaging set" with complete volumetric, strain, and scar imaging, multiple imaging sets with complete strain and volumetric data were obtained during the post-CRT scan for biventricular pacing (BIVP), LV pacing (LVP), and asynchronous atrial pacing modes by reprogramming the device outside the scanner between imaging sets., Results: 100 CMRs with a total of 162 imaging sets were performed in 50 patients (median age 70 years [IQR: 50-86 years]; 48% female). Reduction in LV end-diastolic volumes (P = 0.002) independent of CRT pacing were more prominent than corresponding reductions in right ventricular end-diastolic volumes (P = 0.16). A clear dependence of the optimal CRT pacing mode (BIVP vs LVP) on the PR interval (P = 0.0006) was demonstrated. The LVEF and RVEF improved more with BIVP than LVP with PR intervals ≥240 milliseconds (P = 0.025 and P = 0.002, respectively); the optimal mode (BIVP vs LVP) was variable with PR intervals <240 milliseconds. A lower pre-CRT displacement encoding with stimulated echoes (DENSE) CURE-SVD was associated with greater improvements in the post-CRT CURE-SVD (r = -0.69; P < 0.001), LV end-systolic volume (r = -0.58; P < 0.001), and LVEF (r = -0.52; P < 0.001)., Conclusions: CMR evaluation with assessment of multiple pacing modes during a single scan after CRT is feasible and provides useful information for patient care with respect to response and the optimal pacing strategy., Competing Interests: Funding Support and Author Disclosures The work on this project performed by Drs Hanson, Robinson, and Schumann was supported by National Institutes of Health (NIH) training grant T32 EB00384. Dr Epstein’s effort was supported by National Institutes of Health (NIH) grant R01 HL147104. Dr Bilchick’s work on this project was funded by NIH grants R56 HL135556 and R03 HL135463, and American Heart Association grant 17GRNT33671086. Dr Malhotra has research grant support from Biosense Webster. Dr Darby has grant support from Medtronic and Biosense Webster. Dr Mangrum has research grant support from Boston Scientific, CardioFocus, and St. Jude Medical. Drs Kramer and Epstein have received grant support from Siemens Healthineers. Dr Bilchick has research grant support from Medtronic and Siemens Healthineers. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: To use deep learning for suppression of the artifact-generating T 1 -relaxation echo in cine displacement encoding with stimulated echoes (DENSE) for the purpose of reducing the scan time., Methods: A U-Net was trained to suppress the artifact-generating T 1 -relaxation echo using complementary phase-cycled data as the ground truth. A data-augmentation method was developed that generates synthetic DENSE images with arbitrary displacement-encoding frequencies to suppress the T 1 -relaxation echo modulated for a range of frequencies. The resulting U-Net (DAS-Net) was compared with k-space zero-filling as an alternative method. Non-phase-cycled DENSE images acquired in shorter breath-holds were processed by DAS-Net and compared with DENSE images acquired with phase cycling for the quantification of myocardial strain., Results: The DAS-Net method effectively suppressed the T 1 -relaxation echo and its artifacts, and achieved root Mean Square(RMS) error = 5.5 ± 0.8 and structural similarity index = 0.85 ± 0.02 for DENSE images acquired with a displacement encoding frequency of 0.10 cycles/mm. The DAS-Net method outperformed zero-filling (root Mean Square error = 5.8 ± 1.5 vs 13.5 ± 1.5, DAS-Net vs zero-filling, P < .01; and structural similarity index = 0.83 ± 0.04 vs 0.66 ± 0.03, DAS-Net vs zero-filling, P < .01). Strain data for non-phase-cycled DENSE images with DAS-Net showed close agreement with strain from phase-cycled DENSE., Conclusion: The DAS-Net method provides an effective alternative approach for suppression of the artifact-generating T 1 -relaxation echo in DENSE MRI, enabling a 42% reduction in scan time compared to DENSE with phase-cycling., (© 2021 International Society for Magnetic Resonance in Medicine.)

Background: Pulmonary artery proportional pulse pressure (PAPP) was recently shown to have prognostic value in heart failure (HF) with reduced ejection fraction (HFrEF) and pulmonary hypertension. We tested the hypothesis that PAPP would be predictive of adverse outcomes in patients with implantable pulmonary artery pressure monitor (CardioMEMS™ HF System, St. Jude Medical [now Abbott], Atlanta, GA, USA)., Methods: Survival analysis with Cox proportional hazards regression was used to evaluate all-cause deaths and HF hospitalisation (HFH) in CHAMPION trial 1 patients who received treatment with the CardioMEMS device based on the PAPP., Results: Among 550 randomised patients, 274 had PAPP ≤ the median value of 0.583 while 276 had PAPP>0.583. Patients with PAPP≤0.583 (versus PAPP>0.583) had an increased risk of HFH (HR 1.40, 95% CI 1.16-1.68, p=0.0004) and experienced a significant 46% reduction in annualised risk of death with CardioMEMS treatment (HR 0.54, 95% CI 0.31-0.92) during 2-3 years of follow-up. This survival benefit was attributable to the treatment benefit in patients with HFrEF and PAPP≤0.583 (HR 0.50, 95% CI 0.28-0.90, p<0.05). Patients with PAPP>0.583 or HF with preserved EF (HFpEF) had no significant survival benefit with treatment (p>0.05)., Conclusion: Lower PAPP in HFrEF patients with CardioMEMS constitutes a higher mortality risk status. More studies are needed to understand clinical applications of PAPP in implantable pulmonary artery pressure monitors., (Copyright © 2021 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objectives: To compare the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score with the established Society of Thoracic Surgeons (STS) and EuroSCORE II risk prediction models regarding mortality discrimination after aortic and mitral valve surgery., Design: Retrospective cohort study., Setting: Single tertiary academic medical center., Participants: A total of 259 patients who underwent open aortic valve replacement or open mitral valve repair/replacement from 2009-2014., Interventions: Retrospective chart review., Measurements and Main Results: MAGGIC, STS, and EuroSCORE II risk scores for each patient were studied using binary logistic regression and receiver operating characteristic analysis for the primary endpoint of one-year mortality and secondary endpoint of 30-day mortality. One-year mortality C-statistics were similar across risk scores (STS 0.709, 95% confidence interval [CI] 0.578-0.841; MAGGIC 0.673, 95% CI 0.547-0.799; EuroSCORE II 0.642, 95% CI 0.521-0.762; p = 0.56 between STS and MAGGIC; p = 0.20 between STS and EuroSCORE II; and p = 0.69 between MAGGIC and EuroSCORE II). Thirty-day mortality C-statistics also were similar between STS (0.797, 95% CI 0.655-0.939; p < 0.0001 v null hypothesis), MAGGIC (0.721, 95% CI 0.581-0.860; p = 0.33 v STS), and EuroSCORE II (0.688, 95% CI 0.557-0.818; p = 0.06 v STS; p = 0.68 v MAGGIC)., Conclusions: The MAGGIC risk score performs similarly to STS and EuroSCORE II risk models in mortality discrimination after aortic and mitral valve surgery, albeit in a small sample size. This finding has important implications in establishing MAGGIC as a viable prognostic model in this population subset, with fewer variables and ease of use representing key advantages over STS and EuroSCORE II., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Thermally induced cardiac lesions result in necrosis, edema, and inflammation. This tissue change may be seen with ultrasound. In this study, we sought to use intracardiac echocardiography (ICE) to evaluate pulmonary vein tissue morphology and assess the acute tissue changes that occur following radiofrequency (RF) or laser ablation for atrial fibrillation (AF)., Methods and Results: Patients with AF underwent pulmonary vein isolation (PVI) using irrigated RF or laser balloon. Pre- and post-ablation ICE imaging was performed from within each pulmonary vein (PV). At least 10 transverse imaging planes per PV were evaluated and each plane was divided into eight segments. The PV/atrial wall thickness and the luminal area were measured at each segment. Twenty-seven patients underwent PVI (15 with laser, 12 with RF). Ninety-eight pulmonary veins were analyzed (58 PVs laser; 40 PVs RF). At baseline, there were no regional differences in PV wall thickness in the right-sided veins. The anterior regions of left superior pulmonary vein (LSPV) and left inferior pulmonary vein (LIPV) were significantly thicker compared with the posterior and inferior regions (p < .01). Post-ablation, PV wall thickness in RF group increased 24.1% interquartile range (IQR) (17.2%-36.7%) compared with 1.2% IQR (0.4%-8.9%) in laser group, p = .004. In all PVs, RF ablation resulted in significantly greater percent increase in wall thickness compared with laser. Additionally, RF resulted in more variable changes in regional PV wall thickness; with more increases in wall thickness in anterior versus posterior LSPV (75.4 ± 58.5% vs. 46.8 ± 55.6%, p < .01), anterior versus posterior right superior pulmonary vein (RSPV) (62.9 ± 63.9% vs. 44.6 ± 51.7%, p < .05), and superior versus inferior RSPV (69.1 ± 45.4% vs. 35.9 ± 45%, p < .05). There were no significant regional differences in PV wall thickness changes for the laser group., Conclusions: Rotational ICE can be used to measure acute tissue changes with ablation. Regional variability in baseline wall thickness was nonuniformly present in PVs. Acute tissue changes occurred immediately post-ablation. Compared with laser balloon, RF shows markedly more thickening post-ablation with significant regional variations., (© 2021 Wiley Periodicals LLC.)

Background: Cardiovascular magnetic resonance (CMR) cine displacement encoding with stimulated echoes (DENSE) measures heart motion by encoding myocardial displacement into the signal phase, facilitating high accuracy and reproducibility of global and segmental myocardial strain and providing benefits in clinical performance. While conventional methods for strain analysis of DENSE images are faster than those for myocardial tagging, they still require manual user assistance. The present study developed and evaluated deep learning methods for fully-automatic DENSE strain analysis., Methods: Convolutional neural networks (CNNs) were developed and trained to (a) identify the left-ventricular (LV) epicardial and endocardial borders, (b) identify the anterior right-ventricular (RV)-LV insertion point, and (c) perform phase unwrapping. Subsequent conventional automatic steps were employed to compute strain. The networks were trained using 12,415 short-axis DENSE images from 45 healthy subjects and 19 heart disease patients and were tested using 10,510 images from 25 healthy subjects and 19 patients. Each individual CNN was evaluated, and the end-to-end fully-automatic deep learning pipeline was compared to conventional user-assisted DENSE analysis using linear correlation and Bland Altman analysis of circumferential strain., Results: LV myocardial segmentation U-Nets achieved a DICE similarity coefficient of 0.87 ± 0.04, a Hausdorff distance of 2.7 ± 1.0 pixels, and a mean surface distance of 0.41 ± 0.29 pixels in comparison with manual LV myocardial segmentation by an expert. The anterior RV-LV insertion point was detected within 1.38 ± 0.9 pixels compared to manually annotated data. The phase-unwrapping U-Net had similar or lower mean squared error vs. ground-truth data compared to the conventional path-following method for images with typical signal-to-noise ratio (SNR) or low SNR (p < 0.05), respectively. Bland-Altman analyses showed biases of 0.00 ± 0.03 and limits of agreement of - 0.04 to 0.05 or better for deep learning-based fully-automatic global and segmental end-systolic circumferential strain vs. conventional user-assisted methods., Conclusions: Deep learning enables fully-automatic global and segmental circumferential strain analysis of DENSE CMR providing excellent agreement with conventional user-assisted methods. Deep learning-based automatic strain analysis may facilitate greater clinical use of DENSE for the quantification of global and segmental strain in patients with cardiac disease.

Aims: This study aimed to improve in-person clinical evaluation on the day of heart failure (HF) hospitalization discharge by adding device-measured parameters to predict 30 day HF rehospitalization risk in cardiac resynchronization therapy-defibrillator (CRT-D) patients., Methods and Results: In a cohort of Medicare patients with CRT-Ds, the independent prognostic value of four device-measured parameters was assessed relative to typical clinical parameters associated with rehospitalization risk. Medicare registry, claims, and Medtronic CareLink® Network data for these patients were analysed using logistic regression modelling and net reclassification methods. Among 1563 CRT-D patients, 411 patients had 607 HF hospitalization events during a median 6.3 years of follow-up. Compared with clinical variables alone, impedance measurements resulted in a 28% improvement between the predicted probabilities of having vs. not having a 30 day HF rehospitalization (relative integrated discrimination improvement = 0.28) and a net 42% improvement in the classification of 30 day HF rehospitalization events and non-events after an index HF hospitalization (net reclassification index = 0.42; 95% CI: 0.10, 0.74)., Conclusions: In CRT patients, intrathoracic impedance measurements improve prediction of 30 day HF rehospitalization over clinical characteristics alone. The present study provides supportive data for the routine evaluation of intrathoracic impedance prior to discharge in patient with CRT devices. Furthermore, the models developed in this study could be used to design interventions to improve compliance with Medicare reimbursement guidelines regarding 30 day HF rehospitalization., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Background: P wave indices represent electrocardiographic marker of left atrial pathology. We hypothesized that P wave would be more abnormal in patients presenting with ischemic stroke than a comparable group without ischemic stroke., Methods: We compared P wave terminal force in V1 (PTFV1) between patients admitted with ischemic stroke (case) and patients followed in cardiology clinic (control) at a single medical center. Using logistic regression models, we tested for an association between abnormal PTFV1 (> 4000 µV ms) and ischemic stroke. We also defined several optimal cut-off values of PTFV1 using a LOESS plot and estimated odds ratio of ischemic stroke when moving from one cut-point level to the next higher-level., Results: A total of 297 patients (case 147, control 150) were included. PTFV1 was higher in patients with vs. those without ischemic stroke (median 4620 vs 3994 µV ms; p=0.006). PTFV1 was similar between cardioembolic/cryptogenic and other stroke subtypes. In multivariable analyses adjusting for sex, obesity, age, and hypertension, the association between abnormal PTFV1 and ischemic stroke ceased to be significant (OR 1.53 [0.95, 2.50], p=0.083). Increase to the next cutoff level of PTFV1 (900, 2000, 3000, 4000, 5000, and 6000 µV ms) was associated with 18% increase in odds of having ischemic stroke (vs. no ischemic stroke) (OR 1.18 [1.02, 1.36], p=0.026)., Conclusion: Patients presenting with acute ischemic stroke are more likely to have abnormal PTFV1. These findings from a real-world clinical setting support the results of cohort studies that left atrial pathology manifested as abnormal PTFV1 is associated with ischemic stroke., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Left ventricular (LV) thrombi can arise in patients with ischemic and nonischemic cardiomyopathies. Anticoagulation is thought to reduce the risk of stroke or systemic embolism (SSE), but there are no high-quality data on the effectiveness of direct oral anticoagulants (DOACs) for this indication., Objective: To compare the outcomes associated with DOAC use and warfarin use for the treatment of LV thrombi., Design, Setting, and Participants: A cohort study was performed at 3 tertiary care academic medical centers among 514 eligible patients with echocardiographically diagnosed LV thrombi between October 1, 2013, and March 31, 2019. Follow-up was performed through the end of the study period., Exposures: Type and duration of anticoagulant use., Main Outcomes and Measures: Clinically apparent SSE., Results: A total of 514 patients (379 men; mean [SD] age, 58.4 [14.8] years) with LV thrombi were identified, including 300 who received warfarin and 185 who received a DOAC (64 patients switched treatment between these groups). The median follow-up across the patient cohort was 351 days (interquartile range, 51-866 days). On unadjusted analysis, DOAC treatment vs warfarin use (hazard ratio [HR], 2.71; 95% CI, 1.31-5.57; P = .01) and prior SSE (HR, 2.13; 95% CI, 1.22-3.72; P = .01) were associated with SSE. On multivariable analysis, anticoagulation with DOAC vs warfarin (HR, 2.64; 95% CI, 1.28-5.43; P = .01) and prior SSE (HR, 2.07; 95% CI, 1.17-3.66; P = .01) remained significantly associated with SSE., Conclusions and Relevance: In this multicenter cohort study of anticoagulation strategies for LV thrombi, DOAC treatment was associated with a higher risk of SSE compared with warfarin use, even after adjustment for other factors. These results challenge the assumption of DOAC equivalence with warfarin for LV thrombi and highlight the need for prospective randomized clinical trials to determine the most effective treatment strategies for LV thrombi.

Background: Patients with heart failure having a low expected probability of arrhythmic death may not benefit from implantable cardioverter defibrillators (ICDs)., Objective: The objective was to validate models to identify cardiac resynchronization therapy (CRT) candidates who may not require CRT devices with ICD functionality., Methods: Heart failure (HF) patients with CRT-Ds and non-CRT ICDs from the National Cardiovascular Data Registry and others with no device from 3 separate registries and 3 heart failure trials were analyzed using multivariable Cox proportional hazards regression for survival with the Seattle Heart Failure Model (SHFM; estimates overall mortality) and the Seattle Proportional Risk Model (SPRM; estimates proportional risk of arrhythmic death)., Results: Among 60,185 patients (age 68.6 ± 11.3 years, 31.9% female) meeting CRT-D criteria, 38,348 had CRT-Ds, 11,389 had non-CRT ICDs, and 10,448 had no device. CRT-D patients had a prominent adjusted survival benefit (HR 0.52, 95% CI 0.50-0.55, P < .0001 versus no device). CRT-D patients with SHFM-predicted 4-year survival ≥81% (median) and a low SPRM-predicted probability of an arrhythmic mode of death ≤42% (median) had an absolute adjusted risk reduction attributable to ICD functionality of just 0.95%/year with the majority of survival benefit (70%) attributable to CRT pacing. In contrast, CRT-D patients with SHFM-predicted survival median had substantially more ICD-attributable benefit (absolute risk reduction of 2.6%/year combined; P < .0001)., Conclusions: The SPRM and SHFM identified a quarter of real-world, primary prevention CRT-D patients with minimal benefit from ICD functionality. Further studies to evaluate CRT pacemakers in these low-risk CRT candidates are indicated., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: This study sought to determine if combining the Seattle Heart Failure Model (SHFM-D) and cardiac magnetic resonance (CMR) provides complementary prognostic data for patients with cardiac resynchronization therapy (CRT) defibrillators., Background: The SHFM-D is among the most widely used risk stratification models for overall survival in patients with heart failure and implantable cardioverter-defibrillators (ICDs), and CMR provides highly detailed information regarding cardiac structure and function., Methods: CMR Displacement Encoding with Stimulated Echoes (DENSE) strain imaging was used to generate the circumferential uniformity ratio estimate with singular value decomposition (CURE-SVD) circumferential strain dyssynchrony parameter, and the SHFM-D was determined from clinical parameters. Multivariable Cox proportional hazards regression was used to determine adjusted hazard ratios and time-dependent areas under the curve for the primary endpoint of death, heart transplantation, left ventricular assist device, or appropriate ICD therapies., Results: The cohort consisted of 100 patients (65.5 [interquartile range 57.7 to 72.7] years; 29% female), of whom 47% had the primary clinical endpoint and 18% had appropriate ICD therapies during a median follow-up of 5.3 years. CURE-SVD and the SHFM-D were independently associated with the primary endpoint (SHFM-D: hazard ratio: 1.47/SD; 95% confidence interval: 1.06 to 2.03; p = 0.02) (CURE-SVD: hazard ratio: 1.54/SD; 95% confidence interval: 1.12 to 2.11; p = 0.009). Furthermore, a favorable prognostic group (Group A, with CURE-SVD <0.60 and SHFM-D <0.70) comprising approximately one-third of the patients had a very low rate of appropriate ICD therapies (1.5% per year) and a greater (90%) 4-year survival compared with Group B (CURE-SVD ≥0.60 or SHFM-D ≥0.70) patients (p = 0.02). CURE-SVD with DENSE had a stronger correlation with CRT response (r = -0.57; p < 0.0001) than CURE-SVD with feature tracking (r = -0.28; p = 0.004)., Conclusions: A combined approach to risk stratification using CMR DENSE strain imaging and a widely used clinical risk model, the SHFM-D, proved to be effective in this cohort of patients referred for CRT defibrillators. The combined use of CMR and clinical risk models represents a promising and novel paradigm to inform prognosis and device selection in the future., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: ECG imaging (ECGI) with phase mapping has been used to identify rotational activity non-invasively that can be targeted during atrial fibrillation (AF) ablation. Acute termination of AF using this method has shown improved clinical outcomes. In this study we sought to evaluate whether patterns of rotational density are associated with acute procedural outcomes when using a step-wise ablation strategy., Methods: 50 patients with persistent or long-standing persistent AF underwent non-invasive 3D mapping with CardioInsight™ prior to AF ablation. Composite maps of rotational activity were created and prioritized based on the density of rotations on a biatrial model. Stepwise ablation of pulmonary vein isolation (PVI) ± rotations ± linear lesions was done with AF termination as the procedural endpoint., Results: Acute termination of AF was achieved in 34 patients (68%). Median number of rotations in the left atrium (LA), interatrial septum and right atrium (RA) were 22.2 (9.4 to 29.3), 12.0 (4.3 to 13.4), 25.0 (14.5 to 31.3), respectively. In patients with acute AF termination, a higher number of rotations in the LA was observed, 20.3 (10.0 to 37.1) compared to 10.6 (7.7 to 17.2) in the RA (p = 0.02). Additionally, high density of rotations in the posterior inferior right atrium (segment 2B on the biatrial model) was observed in patients without acute AF termination (p = 0.02)., Conclusion: Acute termination of persistent and long-standing persistent AF using rotational ablation guided by ECGI phase mapping can be achieved in a high percentage of both index and re-do cases. The distribution and pattern of these rotations may be associated with procedural outcomes and could potentially be used to stratify patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Pulmonary arterial hypertension (PAH) is characterised by remodelling of the pulmonary vasculature leading to right ventricular (RV) failure. The failing RV, through interventricular uncoupling, deleteriously impacts the left ventricle and overall cardiac efficiency. We hypothesised that the ratio of the pulmonary artery pulse pressure to the systemic pulse pressure ("pulmonary-systemic pulse pressure ratio", or PS-PPR) would be associated with mortality in PAH., Methods: We conducted a retrospective analysis of 262 patients in the National Institute of Health Primary Pulmonary Hypertension Registry (NIH-PPH). We evaluated the association between the PS-PPR and mortality after adjustment for the Pulmonary Hypertension Connection (PHC) risk equation., Results: Among 262 patients (mean age 37.5±15.8years, 62.2% female), median PS-PPR was 1.04 (IQR 0.79-1.30). In the Cox proportional hazards regression model, each one unit increase in the PS-PPR was associated with more than a two-fold increase in mortality during follow-up (HR 2.06, 95% CI 1.40-3.02, p=0.0002), and this association of PS-PPR with mortality remained significant in the multivariable Cox model adjusted for the PHC risk equation, mean pulmonary artery pressure, and body mass index (BMI) (adjusted HR 1.81, 95% CI 1.13-2.88, p=0.01). Furthermore, PS-PPR in the upper quartile (>1.30) versus quartiles 1-3 was associated with a 68% increase in mortality after adjustment for these same covariates (adjusted HR 1.68, 95% CI 1.13-2.50, p=0.01)., Conclusions: Pulmonary-systemic pulse pressure ratio, a marker of biventricular efficiency, is associated with survival in PAH even after adjustment for the PHC risk equation. Further studies are needed on the wider applications of PS-PPR in PAH patients., (Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Pulmonary artery (PA) pulsitility index (PAPi) is a novel haemodynamic index shown to predict right ventricular failure in acute inferior myocardial infarction and post left ventricular assist device surgery. We hypothesised that PAPi calculated as [PA systolic pressure - PA diastolic pressure]/right atrial pressure (RAP) would be associated with mortality in the National Institutes of Health Registry for Primary Pulmonary Hypertension (NIH-RPPH)., Methods: The impact of PAPi, the Pulmonary Hypertension Connection (PHC) risk score, right ventricular stroke work, pulmonary artery capacitance (PAC), other haemodynamic indices, and demographic characteristics was evaluated in 272 NIH-RPPH patients using multivariable Cox proportional hazards (CPH) regression and receiver operating characteristic (ROC) analysis., Results: In the 272 patients (median age 37.7+/-15.9years, 63% female), the median PAPi was 5.8 (IQR 3.7-9.2). During 5years of follow-up, 51.8% of the patients died. Survival was markedly lower (32.8% during the first 3years) in PAPi quartile 1 compared with the remaining patients (58.5% over 3years in quartiles 2-4; p<0.0001). The best multivariable CPH survival model included PAPi, the PHC-Risk score, PAC, and body mass index (BMI). In this model, the adjusted hazard ratio for death with increasing PAPi was 0.946 (95% CI 0.905-0.989). The independent ROC areas for 5-year survival based on bivariable logistic regression for PAPi, BMI, PHC Risk, and PAC were 0.63, 0.62, 0.64, and 0.65, respectively (p<0.01). The ROC area for 5-year survival for the multivariable logistic model with all four covariates was 0.77 (p<0.0001)., Conclusions: Pulmonary artery pulsatility index was independently associated with survival in PAH, highlighting the utility of PAPi in combination with other key measures for risk stratification in this population., (Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Despite improvements in ST elevation myocardial infarction (STEMI) care, total ischemic time remains long in patients who present late. Our goal was to identify predictors of very late presentation (≥12 h) of STEMI and determine long-term mortality., Methods: We retrospectively examined consecutive patients admitted with STEMI to our institution using the ACTION Registry™. Time of symptom onset to first medical contact (FMC) was calculated and categorized as <12 h or ≥12 h. Predictors of very late presentation were determined., Results: Compared to patients who presented <12 h (n = 365), those who presented ≥12 h (n = 49) after symptom onset were more likely women, diabetics, and those with prior coronary revascularization. In addition, patients who presented ≥12 h had worse ventricular function, were less likely to report chest pain, and were less likely to be transported by ambulance and to undergo coronary angiography. Late presenters had higher rates of heart failure, longer hospitalizations, and were less likely to be discharged home. Diabetes, female sex, and absence of chest pain were strong predictors of late presentation. Long-term survival was significantly lower in late presenters (73% vs. 93%, p = 0.007)., Conclusions: Female sex, diabetes, and absence of chest pain are strong predictors of presentation delay, and long-term mortality is significantly increased in those presenting very late.

Background: Pulmonary hypertension (PH) is characterized by increased pulmonary vascular resistance leading to right heart failure. Elevated right atrial (RA) pressure reflects right ventricular (RV) pressure overload and is an established risk factor for mortality in PH. We hypothesized that PH patients with an increased ratio of RA to LA volume index (RAVI/LAVI), would have increased mortality., Methods: We evaluated the association of RAVI/LAVI with mortality in 124 patients seen at a single academic center's PH clinic after adjusting for the REVEAL risk score, an established risk score in PH. LA and RA volume indices were measured in the four-and two-chamber views by two independent researchers. Multivariable logistic regression was used to model the independent association of RAVI/LAVI with survival., Results: Among 124 patients (mean age 62 ± 12.7 years, 68.6% female), each unit increase in RAVI/LAVI was associated with a nearly twofold increase in mortality (OR: 1.91, 95% CI: 1.20-3.04). In a multivariable logistic regression, each unit increase in RAVI/LAVI was associated with a nearly twofold increase in mortality (OR: 1.73, 95% CI: 1.003-2.998). Furthermore, RAVI/LAVI in the highest quartile (>1.42) was significantly associated with elevated right atrial pressure (RAP) to pulmonary artery wedge pressure ratio (RAP/PAWP) (0.76 ± 0.41, P = 0.02) compared with the lowest quartile (<0.77), suggesting an interaction between invasive hemodynamic data, atrial structural changes, and mortality in PH., Conclusions: Increased RAVI/LAVI in PH is associated with decreased survival and accounts for atrial structural remodeling related to invasive hemodynamics. These findings support further study of this index in predicting outcomes in PH., (© 2018 Wiley Periodicals, Inc.)

Background: Self-reported poor sleep quality has been suggested in patients with AF. Slow wave sleep (SWS) is considered the most restorative sleep stage and represents an important objective measure of sleep quality. The aim of this study was to compare quantity of SWS between patients with and without AF., Methods and Results: We included patients with and without a documented history of AF by reviewing clinically indicated polysomnography data from a single sleep center. Patients on medications with potential influence on sleep architecture were excluded. Logistic regression was performed to determine the association between AF and SWS time (low vs. high) adjusting for age, gender, body mass index, and sleep apnea. In a 2:1 case-control set-up, a total of 205 subjects (139 with AF, 66 without AF) were included. Mean age was 62 (SD: 14.3) years and 59% were men. Patients with AF had lower SWS time (11.1 vs. 16.6 min, p=0.02). In multivariable analysis, prevalent AF was associated with low SWS independent of sleep apnea and other potential confounders (OR 2.5 [1.3, 5.0], p=0.006). Limiting the analysis to patients whose total sleep time was greater than 4 hours (by excluding N=31) resulted in more robust results (OR 3.9 [1.7, 9.7]. p=0.002)., Conclusion: AF is associated with more impaired sleep quality as indicated by lower quantity of SWS. More studies are needed to explore the mechanistic interactions between AF and sleep.