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Right ventricular (RV) pressure-volume (PV) loops require postacquisition volume calibration by cardiac MRI (CMR) or hypertonic saline (HS). We defined the impact of these 2 volume calibration methods on rest-to-exercise ventricular contractility (end-systolic elastance: Ees), arterial afterload (Ea), and coupling (Ees/Ea). In a prospective study, 82 RV PV-loop datapoints (rest, exercise stages every 25 W, and recovery) and CMR were acquired in 19 participants. In comparison to CMR, HS-based calibration overestimated RV end-systolic volume at rest, mean (SD) by +38 ml (48) and end-diastolic volume by +46 ml (68), resulting in underestimated right ventricular ejection fraction (RVEF) by −8%. However, Ees and Ea were similar at rest (r 2 = 0.76 and 0.71, respectively, p < 0.001 for both), and Ees:Ea was identical (r 2 = 1.00, p < 0.001). Exercise metrics also remained similar: RV reserve (ΔEes) and change in coupling (ΔEes/Ea). In comparison to CMR (gold-standard), HS-based calibration underestimates RVEF at rest; however, it is a robust approach for measuring coupling and RV reserve. [ABSTRACT FROM AUTHOR]

Dystrophinopathies, such as Duchenne and Becker muscular dystrophy, frequently lead to cardiomyopathy, being its primary cause of mortality. Detecting cardiac dysfunction early is crucial, but current imaging methods lack insight into microstructural remodeling. This study aims to assess the potential of cardiac magnetic resonance (CMR) parametric mappings for early detection of myocardial involvement in dystrophinopathies and explores whether distinct involvement patterns may indicate impending dysfunction. In this prospective study, 23 dystrophinopathy patients underwent CMR with tissue mappings. To establish a basis for comparison, a control group of 173 subjects was analyzed. CMR protocols included SSFP, T2-weighted and T1-weighted sequences pre and post gadolinium, and tissue mappings for native T1 (nT1), extracellular volume (ECV), and T2 relaxation times. The difference between the left ventricular posterior wall and the interventricular septum was calculated to reveal asymmetric myocardial involvement. Significant differences in LV ejection fraction (LVEF), myocardial mass, and late gadolinium enhancement confirmed abnormalities in patients. Tissue mappings: nT1 (p < 0.001) and ECV (p = 0.002), but not T2, displayed substantial variations, suggesting sensitivity to myocardial involvement. Asymmetric myocardial involvement in nT1 (p = 0.01) and ECV (p = 0.012) between septal and LV posterior wall regions was significant. While higher mapping values didn't correlate with dysfunction, asymmetric involvement in nT1 (ρ=-0.472, p = 0.023) and ECV (ρ=-0.460, p = 0.049) exhibited a significant negative correlation with LVEF. CMR mappings show promise in early myocardial damage detection in dystrophinopathies. Although mapping values may not directly correspond to dysfunction, the negative correlation between asymmetric involvement in nT1 and ECV with LVEF suggests their potential as early biomarkers. Larger, longitudinal studies are needed for a comprehensive understanding and improved risk stratification in dystrophinopathies. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the test–retest repeatability of radiomic features in myocardial native T1 and T2 mapping. Methods: In this prospective study, 50 healthy volunteers (29 women and 21 men, mean age 39.4 ± 13.7 years) underwent two identical cardiac magnetic resonance imaging (MRI) examinations at 1.5 T. The protocol included native T1 and T2 mapping in both short-axis and long-axis orientation. For T1 mapping, we investigated standard (1.9 × 1.9 mm) and high (1.4 × 1.4 mm) spatial resolution. After manual segmentation of the left ventricular myocardium, 100 radiomic features from seven feature classes were extracted and analyzed. Test–retest repeatability of radiomic features was assessed using the intraclass correlation coefficient (ICC) and classified as poor (ICC < 0.50), moderate (0.50–0.75), good (0.75–0.90), and excellent (> 0.90). Results: For T1 maps acquired in short-axis orientation at standard resolution, repeatability was excellent for 6 features, good for 29 features, moderate for 19 features, and poor for 46 features. We identified 15 features from 6 classes which showed good to excellent reproducibility for T1 mapping in all resolutions and all orientations. For short-axis T2 maps, repeatability was excellent for 6 features, good for 25 features, moderate for 23 features, and poor for 46 features. 12 features from 5 classes were found to have good to excellent repeatability in T2 mapping independent of slice orientation. Conclusion: We have identified a subset of features with good to excellent repeatability independent of slice orientation and spatial resolution. We recommend using these features for further radiomics research in myocardial T1 and T2 mapping. Key Points: QuestionThe study addresses the need for reliable radiomic features for quantitative analysis of the myocardium to ensure diagnostic consistency in cardiac MRI. FindingsWe have identified a subset of radiomic features demonstrating good to excellent repeatability in native T1 and T2 mapping independent of slice orientation and resolution. Clinical relevanceRadiomic features have been proposed as diagnostic and prognostic biomarkers in various heart diseases. By identifying a subset of particularly reproducible radiomic features our study serves to inform the selection of radiomic features in future research and clinical applications. [ABSTRACT FROM AUTHOR]

Objectives: This single-center retrospective study evaluated the long-term (~5 years) prognostic value of dipyridamole stress cardiac magnetic resonance (CMR) in patients with known or suspected coronary artery disease (CAD), assessing the impact of both key phases of the ischemic cascade (perfusion and wall motion). Material and methods: We considered 322 consecutive patients who underwent dipyridamole stress CMR. Abnormal wall motion at rest and after dipyridamole, perfusion at stress and at rest, and late gadolinium enhancement (LGE) were analyzed. End-points were non-fatal myocardial infarction, unplanned late revascularization (60 days after CMR), and cardiac death. Results: Forty-four patients were excluded because they underwent early revascularization (within 60 days after stress CMR), leading to a final population of 278 patients (73 females, 62.42 ± 10.50 years). A positive stress CMR was found in 78 (28.1%) patients; 50 patients had a reversible stress perfusion defect in at least one myocardial segment and 28 had a reversible stress perfusion defect plus worsening of stress wall motion in comparison with the rest. During a mean follow-up time of 59.34 ± 31.72 months, 37 (13.3%) cardiac events were recorded: 10 cardiac deaths, one non-fatal myocardial infarction, and 26 late revascularization after unstable angina or myocardial infarction. According to the Cox regression analysis, age, diabetes mellitus, previous revascularization, left ventricular ejection fraction (LVEF), reversible perfusion and perfusion + motion defect, and LGE were significant univariate prognosticators. The presence of associated wall motion abnormality (WMA) did not provide additional prognostic stratification in comparison to the only perfusion defect. In the multivariate Cox regression, the independent predictive factors were diabetes (hazard-ratio-HR = 5.64, p < 0.0001), reversible perfusion defect and reversible perfusion + motion defect vs normal stress CMR (HR = 6.43, p < 0.0001, and HR = 4.57, p = 0.004; respectively), and LVEF (HR = 0.96, p = 0.010). Conclusion: A positive dipyridamole stress CMR predicted a higher long-term risk of cardiovascular events, but the presence of inducible WMA did not show any additional prognostic value over the reversible perfusion defect. Key Points: QuestionThe long-term incremental prognostic value of inducible wall motion abnormalities by stress cardiac MR in patients with known or suspected CAD requires investigation. FindingsThe presence of inducible wall motion abnormalities did not offer additional prognostic value in comparison to the only reversible perfusion defect. Clinical relevanceIndependent from the presence of wall motion abnormalities, more aggressive management may be appropriate in patients with reversible perfusion defects to reduce the long-term risk of cardiovascular events. [ABSTRACT FROM AUTHOR]

Hypertrophic cardiomyopathy (HCM) is the most common genetic heart disease, affecting 1:200 to 1:500 individuals worldwide. Guidelines on the diagnosis and management of HCM have been recently published by the European Society of Cardiology (ESC) and American societies. The ESC guidelines cover a broad range of cardiomyopathies, including HCM, with 119 recommendations, whereas the American guidelines focus exclusively on HCM with 141 specific recommendations. Both guidelines emphasize a comprehensive diagnostic approach, including imaging and genetic testing, but differ in some specific aspects. For example, sudden cardiac death (SCD) risk assessment is a primary point of divergence. The ESC guidelines advocate for the use of a validated Risk-SCD calculator, while the American guidelines rely on specific risk markers for individualized risk evaluation. Management strategies also vary: both guidelines prioritize beta-blockers and calcium channel blockers in patients with resting or provocable left ventricular outflow tract (LVOT) obstruction. If beta-blockers (or verapamil/diltiazem) are ineffective, either disopyramide or the myosin inhibitor mavacamten may be an option with slightly different indications among the two guidelines. Septal reduction therapy is recommended in ESC guidelines for symptomatic patients with significant LVOT gradients, while American guidelines suggest earlier myectomy for certain clinical factors and emphasize shared decision-making. The ESC guidelines recommend sequential atrioventricular pacing and dual-chamber defibrillators for reducing LVOT gradients. The American guidelines focus on genetic testing for risk assessment and suggest periodic cardiac magnetic resonance imaging. This paper provides a detailed comparison of these guidelines, highlighting key differences and areas needing further research and expert debate. [ABSTRACT FROM AUTHOR]

Purpose: Cardiac magnetic resonance is the gold standard for evaluating left‐ventricular ejection fraction (LVEF). Standard protocols, however, can be inefficient, facing challenges due to significant operator and patient involvement. Although the free‐running framework (FRF) addresses these challenges, the potential of the extensive data it collects remains underutilized. Therefore, we propose to leverage the large amount of data collected by incorporating interbin cardiac motion compensation into FRF (FRF‐MC) to improve both image quality and LVEF measurement accuracy, while reducing the sensitivity to user‐defined regularization parameters. Methods: FRF‐MC consists of several steps: data acquisition, self‐gating signal extraction, deformation field estimations, and motion‐resolved reconstruction with interbin cardiac motion compensation. FRF‐MC was compared with the original 5D‐FRF method using LVEF and several image‐quality metrics. The cardiac regularization weight (λc$$ {\lambda}_c $$) was optimized for both methods by maximizing image quality without compromising LVEF measurement accuracy. Evaluations were performed in numerical simulations and in 9 healthy participants. In vivo images were assessed by blinded expert reviewers and compared with reference standard 2D‐cine images. Results: Both in silico and in vivo results revealed that FRF‐MC outperformed FRF in terms of image quality and LVEF accuracy. FRF‐MC reduced temporal blurring, preserving detailed anatomy even at higher cardiac regularization weights, and led to more accurate LVEF measurements. Optimized λc$$ {\lambda}_c $$ produced accurate LVEF for both methods compared with the 2D‐cine reference (FRF‐MC: 0.59% [−7.2%, 6.0%], p = 0.47; FRF: 0.86% [−8.5%, 6.7%], p = 0.36), but FRF‐MC resulted in superior image quality (FRF‐MC: 2.89 ± 0.58, FRF: 2.11 ± 0.47; p < 10−3). Conclusion: Incorporating interbin cardiac motion compensation significantly improved image quality, supported higher cardiac regularization weights without compromising LVEF measurement accuracy, and reduced sensitivity to user‐defined regularization parameters. [ABSTRACT FROM AUTHOR]

Purpose: To compare two blind source separation (BSS) techniques to principal component analysis and the electrocardiogram for the identification of cardiac triggers in self‐gated free‐running 5D whole‐heart MRI. To ascertain the precision and robustness of the techniques, they were compared in three different noise and contrast regimes. Methods: The repeated superior–inferior (SI) projections of a 3D radial trajectory were used to extract the physiological signals in three cardiac MRI cohorts: (1) 9 healthy volunteers without contrast agent injection at 1.5T, (2) 30 ferumoxytol‐injected congenital heart disease patients at 1.5T, and (3) 12 gadobutrol‐injected patients with suspected coronary artery disease at 3T. Self‐gated cardiac triggers were extracted with the three algorithms (principal component analysis [PCA], second‐order blind identification [SOBI], and independent component analysis [ICA]) and the difference with the electrocardiogram triggers was calculated. PCA and SOBI triggers were retained for image reconstruction. The image sharpness was ascertained on whole‐heart 5D images obtained with PCA and SOBI and compared among the three cohorts. Results: SOBI resulted in smaller trigger differences in Cohorts 1 and 3 compared to PCA (p < 0.01) and in all cohorts compared to ICA (p < 0.04). In Cohorts 1 and 3, the sharpness increased significantly in the reconstructed images when using SOBI instead of PCA (p < 0.03), but not in Cohort 2 (p = 0.4). Conclusion: We have shown that SOBI results in more precisely extracted self‐gated triggers than PCA and ICA. The validation across three diverse cohorts demonstrates the robustness of the method against acquisition variability. [ABSTRACT FROM AUTHOR]

Objective To explore the effect of focused solution mode psychological nursing on anxiety and success rate of cardiac magnetic resonance examination. Methods A total of 70 patients with cardiac magnetic resonance examination in our hospital were selected as the subjects of this study, and randomly divided into control group and research group, 35 cases in each group, according to the order of admission to the hospital. The two groups were respectively given routine psychological nursing and psychological nursing intervention based on focused solution mode, and the anxiety situation and the success rate of examination were compared between the two groups. Results The scores of anxiety (anxious mood, nervousness, fear, depressive mood, cognitive function, somatic anxiety, behavior during talks) in the study group were significantly lower than those in the control group (P＜0. 05). The success rate was 77. 1% (27/35) in the control group and 97. 1% (34/35) in the study group, and the success rate in the study group was significantly higher than that in the control group (P＜0. 05). Conclusion Psychological nursing based on focused solution model can effectively improve the anxiety of patients undergoing cardiac magnetic resonance examination, ensure the success rate of examination. [ABSTRACT FROM AUTHOR]

Introduction: Right heart catheterization (RHC) is the diagnostic standard for establishing residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). A potential non-invasive alternative diagnostic test could be electrocardiography (ECG)-derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO). Methods: We studied 66 CTEPH patients who underwent PEA. A subgroup of 20 patients also had a cardiac MRI before and after PEA. The diagnostic performance of the VG-RVPO for the detection of residual PH as well as the potential to replace RHC were assessed. Different cut-off values to define a normal VG-RVPO were evaluated. Also, we evaluated the association between mean pulmonary artery pressure (mPAP) and CMR derived indexed right ventricular (RV) mass and the VG-RVPO. Results: During follow-up, 28 patients had residual PH (42%). A decrease in VG-RVPO after PEA was associated with decrease in mPAP or indexed RV mass post PEA (r = 0.55, p < 0.05 and r = 0.64, p < 0.05, respectively). If a normal VG-RVPO would exclude residual PH, the need for RHC would be reduced with 15–48%, but up to 36% of the CTEPH patients with residual PH would have been missed as they had a normal VG-RVPO. Conclusion: Although there was an association between the change in VG-RPVO and changes in mPAP or indexed RV mass, our study demonstrated that VG-RPVO has limited value in excluding the presence of residual PH post-PEA as up to 36% of the CTEPH patients with residual PH would have been missed if residual PH would have been excluded based on a normal VG-RVPO. [ABSTRACT FROM AUTHOR]

The December highlights from the Circulation family of journals cover various topics in cardiovascular medicine. Articles include a study on renal outcomes in heart failure patients, the use of deep-learning neural networks in predicting cardiovascular prognosis, the comparison of abdominal and coronary calcification in Black adults, an analysis of ischemia severity and coronary artery disease, the real-world experience of pulsed field ablation for atrial fibrillation, and a model to prioritize variants of undetermined significance. These studies provide valuable insights into different aspects of cardiovascular health and treatment. [Extracted from the article]

BACKGROUND: Current outcomes from catheter ablation for scar-dependent ventricular tachycardia (VT) are limited by high recurrence rates and long procedure durations. Personalized heart digital twin technology presents a noninvasive method of predicting critical substrate in VT, and its integration into clinical VT ablation offers a promising solution. The accuracy of the predictions of digital twins to detect invasive substrate abnormalities is unknown. We present the first prospective analysis of digital twin technology in predicting critical substrate abnormalities in VT. METHODS: Heart digital twin models were created from 18 patients with scar-dependent VT undergoing catheter ablation. Contrast-enhanced cardiac magnetic resonance images were used to reconstruct finite-element meshes, onto which regional electrophysiological properties were applied. Rapid-pacing protocols were used to induce VTs and to define the VT circuits. Predicted optimum ablation sites to terminate all VTs in the models were identified. Invasive substrate mapping was performed, and the digital twins were merged with the electroanatomical map. Electrogram abnormalities and regions of conduction slowing were compared between digital twin–predicted sites and nonpredicted areas. RESULTS: Electrogram abnormalities were significantly more frequent in digital twin–predicted sites compared with nonpredicted sites (468/1029 [45.5%] versus 519/1611 [32.2%]; P <0.001). Electrogram duration was longer at predicted sites compared with nonpredicted sites (82.0±25.9 milliseconds versus 69.7±22.3 milliseconds; P <0.001). Digital twins correctly identified 21 of 26 (80.8%) deceleration zones seen on isochronal late activation mapping. CONCLUSIONS: Digital twin–predicted sites display a higher prevalence of abnormal and prolonged electrograms compared with nonpredicted sites and accurately identify regions of conduction slowing. Digital twin technology may help improve substrate-based VT ablation. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04632394. [ABSTRACT FROM AUTHOR]

Obesity is a known risk factor for heart failure with preserved ejection fraction (HFpEF) and is considered a distinct phenotype with more concentric remodeling. Epicardial adipose tissue (EAT) is also increased in obesity-related HFpEF and is associated with adverse events. The cardiac magnetic resonance (CMR) substudy of the SUMMIT trial aimed to examine the effects of tirzepatide on cardiac structure and function with the underlying hypothesis that it would reduce left ventricular (LV) mass and EAT in obesity-related HFpEF. A total of 175 patients with obesity-related HFpEF from the parent study of tirzepatide (2.5 mg subcutaneously weekly, increasing to a maximum of 15 mg weekly) or matching placebo underwent CMR at baseline, which consisted of multiplanar cine imaging. A total of 106 patients completed the CMR and had adequate image quality for analysis of LV and left atrial structure and function and paracardiac (epicardial plus pericardial) adipose tissue at both baseline and 52 weeks. The prespecified primary endpoint of this substudy was between-group changes in LV mass. LV mass decreased by 11 g (95% CI: −19 to −4 g) in the treated group (n = 50) when corrected for placebo (n = 56) (P = 0.004). Paracardiac adipose tissue decreased in the treated group by 45 mL (95% CI: −69 to −22 mL) when corrected for placebo (P < 0.001). The change in LV mass in the treated group correlated with changes in body weight (P < 0.02) and tended to correlate with changes in waist circumference and blood pressure (P = 0.06 for both). The LV mass change also correlated with changes in LV end-diastolic volume and left atrial end-diastolic and end-systolic volumes (P < 0.03 for all). The CMR substudy of the SUMMIT trial demonstrated that tirzepatide therapy in obesity-related HFpEF led to reduced LV mass and paracardiac adipose tissue as compared with placebo, and the change in LV mass paralleled weight loss. These physiologic changes may contribute to the reduction in heart failure events seen in the main SUMMIT trial. (A Study of Tirzepatide [LY3298176] in Participants With Heart Failure With Preserved Ejection Fraction [HFpEF] and Obesity: The SUMMIT Trial; NCT04847557) [Display omitted] [ABSTRACT FROM AUTHOR]

Hypertrophic cardiomyopathy (HCM) is a leading cause of sudden cardiac death. Current diagnosis emphasizes the detection of left ventricular hypertrophy (LVH) using a fixed threshold of ≥15-mm maximum wall thickness (MWT). This study proposes a method that considers individual demographics to adjust LVH thresholds as an alternative to a 1-size-fits-all approach. Left ventricular MWT was measured in 3 cohorts: a Reference Cohort of healthy adults (n = 5,067, no comorbidities), a Population Cohort (n = 43,239, with comorbidities), and an HCM Cohort from 6 international centers (n = 2,424). Measurement used cardiovascular magnetic resonance (CMR) and a validated artificial intelligence algorithm. The Reference Cohort was used to developed demographically adjusted LVH thresholds, and individualized z -scores based on age, sex, and body surface area (BSA), which were used to explore the other cohorts. The traditional ≥15-mm threshold classified 4.3% (n = 1,854) of the Population Cohort as hypertrophic, with a significant sex skew (89% male). Demographic-adjusted LVH thresholds (range: 10-17 mm) reduced ascertainment to 2.2% (n = 945), reducing the sex skew (56% male). Similar reductions in bias with height, weight, and age also occurred. The HCM cohort was found to have a 2:1 male-to-female ratio. A significant proportion of patients received diagnoses of HCM despite having MWT below the traditional LVH threshold (<15 mm): 27% of female individuals and 18% of male individuals. Using demographic-adjusted LVH thresholds reduced these proportions to 7% of female individuals and 15% of male individuals (P < 0.0001). Female patients had lower absolute MWT (18 mm vs 19 mm; P < 0.001) but higher MWT z -scores (5.1 vs 4.5; P = 0.05). Age, sex, and body size influence the normal heart MWT. Using a fixed LVH threshold ≥15 mm biases LVH ascertainment in both population and HCM cohorts. A demographic-adjusted approach for LVH improves ascertainment and diagnostic accuracy. [Display omitted] [ABSTRACT FROM AUTHOR]

This study aims to investigate the effects of β-3-hydroxybutyrate (β-3-OHB) infusion on myocardial metabolic flexibility using hyperpolarized [2-13C]pyruvate magnetic resonance spectroscopy (MRS) in the pig heart. We hypothesized that β-3-OHB infusion will cause rapid, quantifiable alterations in tricarboxylic acid (TCA) cycle flux as measured non-invasively by 13C MRS and reflect myocardial work. Five female Danish landrace pigs underwent β-3-OHB infusion during a hyperinsulinemic euglycemic clamp (HEC). Cardiac metabolism and hemodynamics were monitored using hyperpolarized [2-13C]pyruvate MRS and cardiac MRI. β-3-OHB infusion during HEC resulted in significant increases in cardiac output over baseline (from 1.9 to 3.8 L/min, p = 0.0011) and heart rate (from 51 to 85 bpm, p = 0.0004). Metabolic analysis showed a shift towards increased lactate production and decreased levels of acetyl-carnitine and glutamate during β-3-OHB infusion. Following the termination of the infusion, a normalization of these metabolic markers was observed. These results demonstrate the profound metabolic adaptability of the myocardium to ketone body utilization. The infusion of Na-β-3-OHB significantly alters both the hemodynamics and metabolism of the porcine heart. The observed increase in cardiac output and metabolic shifts towards lactate production suggest that ketone bodies could potentially enhance cardiac function by providing an efficient-energy substrate that, if provided, is preferentially used. This study provides new insights into the metabolic flexibility of the heart and hints at the potential therapeutic benefits of ketone interventions in heart failure treatment. [ABSTRACT FROM AUTHOR]

Myocardial fibrosis is a key healing response after myocardial infarction driven by activated fibroblasts. Gallium-68-labeled fibroblast activation protein inhibitor ([68Ga]-FAPI) is a novel positron-emitting radiotracer that binds activated fibroblasts. The aim of this study was to investigate the intensity, distribution, and time-course of fibroblast activation after acute myocardial infarction. A total of 40 patients with acute myocardial infarction underwent hybrid [68Ga]FAPI-46 positron emission tomography and cardiac magnetic resonance and were compared with matched control subjects (n = 19) and those with chronic (>2 years) myocardial infarction (n = 20). Intensity of [68Ga]FAPI-46 uptake was quantified by maximum target-to-background ratio (TBR max). Burdens of fibroblast activation and scar were assessed by percent myocardial involvement of [68Ga]FAPI-46 uptake and late gadolinium enhancement, respectively. Myocardial [68Ga]FAPI-46 uptake was observed in the acute infarct and peri-infarct regions that exceeded the extent of late gadolinium enhancement (burden 27.8% ± 12.4% vs 15.2% ± 10.6%; P < 0.001). One-third of patients also demonstrated right ventricular involvement. Myocardial [68Ga]FAPI-46 uptake was most intense at 1 and 2 weeks before declining at 4 and 12 weeks (TBR max 4.0 ± 1.1, 3.7 ± 1.0, 3.1 ± 0.8, and 2.7 ± 0.7; P < 0.001). In comparison with control subjects, increased [68Ga]FAPI-46 uptake was observed in chronic (7 ± 6 years ago) infarcts at lower intensity than acute infarction (TBR max 1.2 ± 0.1 vs 1.7 ± 0.5 vs 4.0 ± 1.1; P < 0.001). Baseline [68Ga]FAPI-46 burden correlated with lower left ventricular ejection fraction (r = −0.606), higher indexed left ventricular end-diastolic volume (r = 0.572), and higher scar burden (r = 0.871) at 1 year (P < 0.001 for all). Increased remote myocardial [68Ga]FAPI-46 uptake was associated with left ventricular dilatation and systolic dysfunction. Myocardial fibroblast activation peaks within a week of acute myocardial infarction and extends beyond the infarct region. It declines slowly with time, persists for years, and is associated with subsequent left ventricular remodeling. (PROFILE-MI–The FAPI Fibrosis Study; NCT05356923) [Display omitted] [ABSTRACT FROM AUTHOR]

Mitral valve prolapse (MVP) is a common condition affecting approximately 3% of the population, typically with a benign clinical course. However, a small subset of patients (5–10%) may develop severe mitral regurgitation or arrhythmias, which can lead to sudden cardiac death (SCD). Among the morphological features of MVP, mitral annular disjunction (MAD) has emerged as a potential marker of malignant MVP, with some studies suggesting an association with ventricular arrhythmias and SCD. MAD refers to a structural abnormality where there is a separation between the posterior mitral annulus and the ventricular myocardium, particularly during systole. Initially described in the 1980s, MAD has been primarily studied through echocardiography, although its dynamic nature during the cardiac cycle has complicated its diagnosis. The clinical significance of MAD has been debated, as its presence is not exclusive to pathological MVP, being observed in structurally normal mitral valves as well. Recent research, using advanced imaging techniques such as three-dimensional echocardiography, cardiac magnetic resonance and computed tomography, has provided a more refined understanding of MAD. These studies suggest that MAD can be found in normal hearts, particularly in the posterior mitral annulus, and is often considered a benign anatomical variant. However, the occurrence of MAD in patients with MVP, especially those with leaflet redundancy, has been linked to an increased risk of arrhythmias and SCD. The exact role of MAD in arrhythmogenesis remains unclear, but it is hypothesized that MAD may contribute to electrical instability by altering the mechanical properties of the mitral valve, potentially promoting fibrosis in the surrounding myocardium. Despite these associations, the direct causal role of MAD in SCD requires further investigation, and it may ultimately prove to be an innocent bystander rather than the primary cause of fatal arrhythmias. Schematic illustration of the current definition of MAD and the new hypothesis [ABSTRACT FROM AUTHOR]

Background: Obesity is common in the heart failure (HF) population and is regarded as an important risk factor for developing HF. Greater skeletal muscle mass has shown to be the underlying protective factor against cardiac failure. Since diabetic mellitus (DM) can impair muscle protein metabolism, leading to skeletal muscle wasting, accompanied by adipose tissue accumulation, sarcopenic obesity (SO) may be a high-risk phenotype with poor outcomes in this specific population, especially in HF with reduced ejection fraction (HFrEF). Thus, the aim of this study was to clarify the clinical profiles, left ventricular (LV) remodeling, and prognostic implications of SO in patients with HFrEF and DM. Methods: A total of 283 patients who underwent cardiac MRI were included. Thoracic skeletal muscle index (SMI) was served as a surrogate of skeletal muscle mass. Patients were stratified according to the median thoracic SMI (42.75 cm2/m2) and body mass index (25 kg/m2). Obesity in conjunction with a SMI lower than the median is referred to as SO. The LV volume and function, as well as the systolic strain, were measured. The clinical characteristics and cardiovascular outcomes (heart failure readmission, cardiovascular mortality and heart transplantation) were recorded. Results: Patients with SO had a greater level of amino-terminal pro-B-type natriuretic peptide and were more likely than nonsarcopenic patients with obesity to present with hypoproteinemia. Among patients with obesity, those with sarcopenia displayed greater LV expansion and more profound LV dysfunction, together with an increase in LV mass. During a median follow-up duration of 35.1 months, a total of 73 (25.8%) subjects reached the composite endpoint, with a worst outcome in the group of patients with SO (log-rank P = 0.04). Multivariable Cox analysis revealed that patients with SO had an approximately 3-fold greater risk of experiencing adverse outcomes than did those with neither sarcopenia nor obesity (hazard ratio: 3.03, 95% confidence interval: 1.39 to 6.63; P = 0.005). Conclusions: SO is a potentially high-risk phenotype with adverse LV remodeling and poor clinical outcomes in diabetic patients with HFrEF that may require more attention. [ABSTRACT FROM AUTHOR]

Background: Chemotherapy-induced cardiotoxicity is a concern for patients with gynecologic cancer. This study aimed to assess left ventricular (LV) myocardial deformation in patients with gynecologic cancer undergoing chemotherapy and to investigate the association between myocardial deformation and chemotherapy factors. Methods: Cardiac magnetic resonance (CMR) was performed to assess LV deformation parameters using CMR tissue tracking based on cine images. Serum myocardial injury biomarker were measured. Deformation parameters were compared between healthy controls and patients. Changes in deformation were assessed as chemotherapy progressed. Correlations between LV deformation parameters, clinical characteristics, and serum myocardial injury biomarkers were also analyzed. Results: A total of 86 patients with gynecologic cancer and 30 normal controls were included. Among the patients, 41 completed CMR follow-up with a median interval of 6 months. Compared to the controls, patients exhibited lower absolute value of global radial strain (GRS) (37.30 ± 8.94% vs. 44.32 ± 8.44%), global circumferential strain (GCS) (-22.12 ± 3.05% vs. -24.08 ± 2.13%) and global longitudinal strain (GLS) (median -15.72% [IQR-17.13 to -13.58%] vs. -17.51 ± 2.00 %) (all p < 0.05). Patients with preserved LV ejection fraction (LVEF) also showed impaired global strain (all p < 0.05). GRS (39.71 ± 8.09% vs. median 30.56% [IQR 26.52 to 38.15%]; p = 0.001), GCS (-23.45 ± 2.09% vs. median -19.71% [IQR -21.71 to -19.10%]; p < 0.001) and GLS (-16.17 ± 2.42% vs. median -12.12% [IQR -14.10 to -8.53%]; p < 0.001) further decreased as the number of chemotherapy cycles increased during follow-up (all p < 0.05). Multivariate analysis showed that GCS was independently associated with the number of chemotherapy regimens (Standard regression coefficient [β] = 0.397, p < 0.001). Conclusions: Myocardial deformation is more sensitive than LVEF in detecting subclinical left ventricular dysfunction in patients with gynecologic cancer undergoing chemotherapy. GCS was associated with the number of chemotherapy regimens. [ABSTRACT FROM AUTHOR]

Background: Primary cardiac echinococcosis is rare, and cardiac alveolar echinococcosis is even rarer and more unusual. Reported cases of this disease are extremely limited, and multimodal imaging provides an important guide to treatment and decision-making. We report a case of cardiac alveolar echinococcosis. Case summary: A 31-year-old male patient with no significant history was diagnosed to have a space-occupying lesion in the mediastinum. Transthoracic echocardiography showed a cystic mass anterior to the right lateral aspect of the right atrium, which did not show enhancement on the enhanced scan. Multidetector computed tomography (MDCT) and cardiac magnetic resonance showed a cystic space-occupying lesion in the right lateral aspect of the right atrium, with mild enhancement of the edges of the lesion and multiple small vesicles on the enhancement scan. Clinicians operated on the patient under suspicion of cardiac echinococcosis and successfully removed the lesion. Ultimately, postoperative histopathologic examination revealed cardiac alveolar echinococcosis. The patient recovered well and was discharged with regular postoperative oral albendazole tablets and regular follow-up reviews. Conclusion: We report a case of cardiac alveolar echinococcosis with multimodal imaging features and therapeutic strategies, an extremely rare cardiac occupying disease. Multimodal imaging is of great help in the diagnosis of this disease, and surgical resection and histopathological diagnosis are essential. After surgery, treatment and follow-up will be carried out based on the results of the histological examination. This rare case emphasizes the integrated diagnosis of cardiac alveolar echinococcosis with clinical, multimodal imaging and pathologic data. [ABSTRACT FROM AUTHOR]

Simple Summary: Heart disease is common in the general population and can complicate the treatment of cancer, particularly in the setting of chemotherapy and immunotherapy, and in the long term following radiation therapy to the chest. Cardiac investigation with electrocardiography and imaging may help diagnose and predict outcomes of patients with cardiovascular complications from cancer therapy. This is important as cardiac events may lead to worse outcomes and may also result in the withholding or withdrawal of potentially lifesaving cancer treatments. Various artificial intelligence tools applied to these different cardiac tests may help suggest increased risk cardiovascular processes and therefore improve the quality and efficiency of care, and potentially reduce the burden of multiple medical tests and hospital presentations for cancer patients. This review summarizes the current landscape of artificial intelligence in evaluating cancer patients for cardiac complications. Cardiovascular diseases and cancer are the leading causes of morbidity and mortality in modern society. Expanding cancer therapies that have improved prognosis may also be associated with cardiotoxicity, and extended life span after survivorship is associated with the increasing prevalence of cardiovascular disease. As such, the field of cardio-oncology has been rapidly expanding, with an aim to identify cardiotoxicity and cardiac disease early in a patient who is receiving treatment for cancer or is in survivorship. Artificial intelligence is revolutionizing modern medicine with its ability to identify cardiac disease early. This article comprehensively reviews applications of artificial intelligence specifically applied to electrocardiograms, echocardiography, cardiac magnetic resonance imaging, and nuclear imaging to predict cardiac toxicity in the setting of cancer therapies, with a view to reduce early complications and cardiac side effects from cancer therapies such as chemotherapy, radiation therapy, or immunotherapy. [ABSTRACT FROM AUTHOR]

Hypertrophic cardiomyopathy (HCM) is often characterized by augmented cardiac contractility, which frequently remains undetectable in its early stages. Emerging evidence suggests that hypercontractility is linked to mitochondrial defects that develop early in HCM progression. However, imaging markers for identifying these early alterations in myocardial function are lacking. We used cardiac magnetic resonance feature tracking (CMR-FT) to assess myocardial strain in a Mybpc3-knockin (KI) mouse model that mimicked human HCM. While homozygous (HOM) mice exhibited cardiac hypertrophy, heterozygous (HET) mice represented an early, asymptomatic stage of HCM. To explore mitochondrial contributions to hypercontractility, we evaluated mitochondrial integrity via scanning electron microscopy (SEM) and correlated these findings with strain abnormalities. Young HET female, but not male mice exhibited significant torsion abnormalities (p = 0.02), reduced left ventricular global longitudinal strain (LVGLS, p = 0.009), and impaired right ventricular global longitudinal strain (RVGLS, p = 0.035) compared to the controls. Strain abnormalities correlated strongly with mitochondrial morphological alterations, including changes in volume and area distribution (R > 0.7). Abnormal myocardial strain patterns, including torsion and GLS, serve as early markers of HCM and are closely associated with underlying mitochondrial dysfunction. The HET Mybpc3-KI HCM model provides important insights into the initial stages of HCM progression, highlighting strain abnormalities and sex-specific differences to enhance early diagnosis and therapeutic strategies. [ABSTRACT FROM AUTHOR]

Introduction: Congenital pericardial agenesis is a rare congenital anomaly resulting from the incomplete development of the pleuropericardial membranes during embryogenesis, leading to the partial or complete absence of the pericardial sac. Although this condition usually remains asymptomatic, it can present with various misleading symptoms such as chest pain (add some other, maybe 2, more prevalent presenting symptoms), making diagnosis challenging. Advanced imaging techniques are crucial for accurate diagnosis and management, especially when usual diagnostic modalities do not achieve a definite diagnosis. Case presentation: The history and diagnostic process of a 16-year-old female who presented with isolated, non-exertional chest pain are detailed. A comprehensive diagnostic work-up was initiated, including chest X-ray (CXR), transthoracic echocardiogram (TTE), CT angiography (CTA), and cardiac magnetic resonance imaging (CMRI). These advanced imaging modalities unveiled the rare and elusive diagnosis of left-sided pericardial agenesis, decisively ruling out other potential causes and shedding light on an extraordinary case that challenges conventional diagnostic pathways. Conclusion: Unilateral pericardial agenesis, though typically benign and often shrouded in clinical obscurity, can manifest with enigmatic symptoms such as isolated chest pain, necessitating a meticulous and comprehensive diagnostic approach. Multimodal imaging is essential for accurate diagnosis and for ruling out complications such as cardiac herniation or coronary artery compression. Considering the absence of significant complications, conservative management was chosen in this case, with the patient being discharged with instructions to monitor for any warning signs. Clinical key message: Clinicians should consider congenital pericardial agenesis as one of the potential causes of unexplained chest pain, particularly when the initial investigations are inconclusive. Advanced imaging techniques (such as CXR and MRI) are vital for confirming the diagnosis and subsequently appropriate and timely management and preventing potential complications. [ABSTRACT FROM AUTHOR]

Abnormal passive stiffness of the heart muscle (myocardium) is evident in the pathophysiology of several cardiovascular diseases, making it an important indicator of heart health. Recent advancements in cardiac imaging and biophysical modeling now enable more effective evaluation of this biomarker. Estimating passive myocardial stiffness can be accomplished through an MRI-based approach that requires comprehensive subject-specific input data. This includes the gross cardiac geometry (e.g. from conventional cine imaging), regional diastolic kinematics (e.g. from tagged MRI), microstructural configuration (e.g. from diffusion tensor imaging), and ventricular diastolic pressure, whether invasively measured or non-invasively estimated. Despite the progress in cardiac biomechanics simulations, developing a framework to integrate multiphase and multimodal cardiac MRI data for estimating passive myocardial stiffness has remained a challenge. Moreover, the sensitivity of estimated passive myocardial stiffness to input data has not been fully explored. This study aims to: (1) develop a framework for integrating subject-specific in vivo MRI data into in silico left ventricular finite element models to estimate passive myocardial stiffness, (2) apply the framework to estimate the passive myocardial stiffness of multiple healthy subjects under assumed filling pressure, and (3) assess the sensitivity of these estimates to loading conditions and myofiber orientations. This work contributes toward the establishment of a range of reference values for material parameters of passive myocardium in healthy human subjects. Notably, in this study, beat-to-beat variation in left ventricular end-diastolic pressure was found to have a greater influence on passive myocardial material parameter estimation than variation in fiber orientation. [ABSTRACT FROM AUTHOR]

Epicardial adipose tissue (EAT) is associated with microvascular obstruction (MVO). However, its association with new-onset atrial arrhythmias after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is unclear. We investigated the correlation of cardiac magnetic resonance (CMR)-measured EAT with MVO and its effect on new-onset atrial arrhythmias after PCI in patients with STEMI. This study employed a single-centre retrospective design. Patients diagnosed with STEMI who underwent CMR after PCI between January 2019 and January 2023 were consecutively included and followed-up regularly. Participants were categorised based on whether they developed new-onset atrial arrhythmia after PCI. In comparison to the non-arrhythmia group, the atrial arrhythmia group exhibited higher values for age, heart rate, peak hs-TnT, peak NT-proBNP, EATV, LAES, LAED, and MVO, alongside reduced LVEF. A positive association was identified between EATV and MVO. Univariate analysis using logistic regression revealed that age, heart rate, hs-TnT level, NT-proBNP level, LVEF, EATV, LAES, LAED, and MVO were significant risk factors for atrial arrhythmia. Multivariate logistic regression analysis further identified age, LAES, EATV, and MVO as independent predictors of atrial arrhythmia. ROC curve analysis produced AUC values of 0.690 for age, 0.584 for LAES, 0.607 for MVO, and 0.769 for EATV. The EATV demonstrated a strong positive relationship with MVO after PCI in patients with STEMI. Age, LAES, EATV, and MVO were independent predictors of new-onset atrial arrhythmias and exhibited substantial prognostic significance. [ABSTRACT FROM AUTHOR]

Accurate segmentation of cardiac structures in magnetic resonance imaging (MRI) is essential for reliable diagnosis and management of cardiovascular disease. Although numerous robust models have been proposed, no single segmentation model consistently outperforms others across all cases, and models that excel on one dataset may not achieve similar accuracy on others or when the same dataset is expanded. This study introduces FCTransNet, an ensemble-based computer-aided diagnosis system that leverages the complementary strengths of Vision Transformer (ViT) models (specifically TransUNet, SwinUNet, and SegFormer) to address these challenges. To achieve this, we propose a novel pixel-level fusion technique, the Intelligent Weighted Summation Technique (IWST), which reconstructs the final segmentation mask by integrating the outputs of the ViT models and accounting for their diversity. First, a dedicated U-Net module isolates the region of interest (ROI) from cine MRI images, which is then processed by each ViT to generate preliminary segmentation masks. The IWST subsequently fuses these masks to produce a refined final segmentation. By using a local window around each pixel, IWST captures specific neighborhood details while incorporating global context to enhance segmentation accuracy. Experimental validation on the ACDC dataset shows that FCTransNet significantly outperforms individual ViTs and other deep learning-based methods, achieving a Dice Score (DSC) of 0.985 and a mean Intersection over Union (IoU) of 0.914 in the end-diastolic phase. In addition, FCTransNet maintains high accuracy in the end-systolic phase with a DSC of 0.989 and an IoU of 0.908. These results underscore FCTransNet's ability to improve cardiac MRI segmentation accuracy. [ABSTRACT FROM AUTHOR]

This paper describes the role of cardiovascular magnetic resonance (CMR) imaging in assessing patients with mitral valve disease. Mitral regurgitation (MR) is one of the most prevalent valvular heart diseases. It often progresses without significant symptoms, leading to left ventricular overload, dysfunction, frequent decompensated heart failure episodes, and excess mortality. Cardiovascular magnetic resonance assessment is recommended for MR when routine ultrasound imaging information is insufficient or discordant. A well-planned CMR can provide an in-depth assessment of the mitral valve apparatus, leaflet morphology, and papillary muscles. In addition, it can precisely inform the impact of MR on left atrial and ventricular remodelling. The review aims to highlight established and emerging techniques for morphological assessment, flow assessment (including regurgitation and stenosis), myocardial assessment, and haemodynamic assessment of mitral valve disease by CMR. It also proposes a simplified clinical flow chart for CMR assessment of the mitral valve. [ABSTRACT FROM AUTHOR]

Backround: Cardiac involvement has been reported in different mitochondrial geno- and phenotypes, including mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like (MELAS) syndrome. However, cardiac manifestations are diverse and not well described. Methods: We prospectively examined cardiac manifestations in 11 adult patients with MELAS syndrome harboring the MTTL1 m.3243A < G-mutation using patient records, cardiac MRI (1.5 Tesla), echocardiography, electrocardiogram (ECG), laboratory tests of cardiac markers (CK, CK-MB, Trop I, BNP), and clinical severity (NMDAS = Newcastle Mitochondrial Disease Scale). Results: Among 11 consecutive patients with MELAS syndrome (73% male, mean age 37.5 ± 10.6 years) cardiac manifestations were found in nine (82%). Pathology was mainly detected using MRI (9 of 11, 82%). Six patients showed diffuse late enhancement in the left ventricle, one a left ventricular ejection fraction (LVEF) below 30%, two with a LVEF in the range of 40–50% in the cardiac MRI, and another five patients presenting diastolic dysfunction as defined by echocardiography. Only one patient with late enhancement on MRI also showed a conduction block in the ECG. There was no correlation between the cardiac manifestations and the NMDAS score or heteroplasmy grade. Conclusions: Cardiac involvement in MELAS syndrome harboring the MTTL1 m.3243A > G mutation mostly entails cardiomyopathy, which was particularly evident in the cardiac MRI. Only one patient (1/11, 9.1%) had conduction defects. Thus, cardiac testing including cardiac MRI, echocardiography and ECG seems to be important for prognosis of MELAS patients. [ABSTRACT FROM AUTHOR]

Background: Epicardial and pericardial adipose tissues are two distinct types of visceral fat in close adherence to the heart and were found to be increased among diabetics. Aim: To investigate the correlation between cardiac magnetic resonance (CMR)-quantified epicardial (EFV) and pericardial fat (PFV) volumes and the complexity of coronary artery disease (CAD) among diabetic and non-diabetic patients. Methods: This was a cross-sectional study that included 111 patients having CAD as indicated by coronary angiography and who underwent CMR. Epicardial and pericardial fat volumes were measured along short-axis CMR-derived images. CAD severity and complexity were evaluated using the syntax score (SS). Patients were classified into diabetic and non-diabetic groups based on their HbA1c and were compared regarding clinical, angiographic, and CMR data. Those with high SS were compared against low/intermediate SS. The correlation of measured EFV and PFV with the SS was evaluated, and possible predictors for high-SS were assessed. Results: Diabetic patients (n = 64, 57.7%) had significantly high syntax scores, and significantly larger absolute and indexed EFV and PFV compared to non-diabetics. Both EFV and PFV showed a significant positive correlation with HbA1c and SS. EFV ≥ 119.55 ml significantly predicted high-SS (AUC = 0.84, 95%CI = 0.76–0.91, sensitivity = 77% and specificity = 82.5%) among the study population. Different cutoff points of EFV significantly predicted high SS among diabetics and non-diabetics with respective reasonable sensitivity and specificity. Age and EFV were consistently predictive of high SS on different multivariable regression models. Conclusion: Increased epicardial adipose tissue was a significant independent predictor of severe and complex CAD, representing a possible risk marker and potential therapeutic target, particularly among diabetics. [ABSTRACT FROM AUTHOR]