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Among patients with chronic kidney disease (CKD), aortic stenosis (AS) is associated with a significantly higher rate of mortality. We aimed to evaluate whether diffuse myocardial fibrosis, determined using native T1 mapping, has prognostic utility in predicting major adverse cardiovascular events (MACEs), including all-cause mortality or heart failure hospitalization, in patients with CKD and severe AS who are evaluated for transcatheter aortic valve implantation. Cardiac magnetic resonance with T1 mapping using the modified Look-Locker inversion recovery technique was performed in 117 consecutive patients with severe AS and CKD (stage ≥3). Patients were followed up to determine the occurrence of MACE. The mean age of the 117 patients in the cohort was 82 ± 8 years. Native T1 was 1,055 ms (25th- to 75th percentiles 1,031 to 1,078 ms), which is higher than previously reported in healthy controls. Patients with higher T1 times were more likely to have higher N-terminal pro-B-type natriuretic peptide levels (4,122 [IQR 1,578 to 7,980] pg/ml vs 1,678 [IQR 493 to 2,851] pg/ml, p = 0.005) and a history of heart failure (33% vs 9%, p = 0.034). After median follow-up of 3.4 years, MACE occurred in 71 patients (61%). The Society of Thoracic Surgeons predicted risk of mortality score (hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.02 to 1.12, p = 0.006), native T11,024 ms (HR 2.10, 95% CI 1.09 to 4.06, p = 0.028), and New York Heart Association class (HR 1.56, 95% 1.09 to 2.34, p = 0.016) were independent predictors of MACE. Longer native T1 was associated with MACE occurrence in patients with CKD and severe AS.

Cardiac magnetic resonance imaging (CMR) image quality can be degraded by artifact in patients with cardiac implantable electronic devices (CIED). We aimed to establish a clinical risk score, so patient selection for diagnostic CMR could be optimised.In this retrospective cohort study, CMRs performed for clinical use in subjects with CIED from January 2016 to May 2019 were reviewed. Subject anthropometry, CIED generator/lead specifications and pre-scan chest X-ray (CXR) measurements were collected. Generator-related artifact size was measured on axial steady state free precession images. Interpretability of late gadolinium enhancement (LGE) imaging was performed based on a three-grade visual score attributed to each of 17 myocardial segments.Fifty-seven (57) patients (59±16 years, 74% male) fitted the inclusion criteria. Artifact precluded left ventricle (LV) evaluation (≥5 segments) in 17 (30%). Artifact was more common with implantable cardioverter-defibrillators, related to generator volume, mass, height, width, thickness, and area, along with right ventricular (RV) lead length and diameter (all p0.05). Artifact was associated with distance from generator to LV apex, generator to RV lead tip and shortest distance from generator to heart on CXR (all p0.05). On multivariable regression modelling, RV lead diameter (OR 5.861, 95% CI 1.866-18.407, p=0.002) and distance from generator to LV apex (OR 0.693, 95% CI 0.511-0.940, p=0.019) were independent predictors of artifact. Multivariable predictors were used to develop Device Related CMR Artifact Prediction Score (DR-CAPS), where all patients with DR-CAPS=0 had fully interpretable LGE imaging.Simple, readily available measures, such as lead characteristics and pre-scan CXR measures, can stratify patients via an artifact prediction score to optimise selection for diagnostic CMR.

BACKGROUND: Sinus of Valsalva aneurysms (SVAs) are rare. We assessed the role of multimodality imaging in guiding the contemporary management. METHODS: A single-center retrospective cohort study over a 20-year period was performed. RESULTS: Between January 1997 and June 2017, 103 patients were diagnosed with SVAs (median age: 58 years). Eighty patients presented with non-ruptured SVAs, and 23 with ruptured SVAs. Seventy-six patients underwent surgery, and 27 were conservatively managed. The median durations of follow-up were: 48 months (surgical group) vs. 37.5 months (conservative group). There was no mortality directly attributable to SVA surgery. There were no late complications in the conservative group. Transthoracic echocardiography (TTE) was the first-line imaging investigation (100.0% in surgical group vs. 92.6% in conservative group, P=0.019). Additional imaging studies included: (I) transesophageal echocardiography (TEE): 93.4% in surgical group vs. 22.2% in conservative group, P

IntroductionIsolated tricuspid valve surgery (TVS) may be associated with high morbidity and mortality. The aim of this study was to investigate the association of preoperative imaging and haemodynamic data derived from echocardiography (ECHO), cardiac magnetic resonance (CMR) and right heart catheterisation (RHC) with postoperative outcomes following TVS.MethodsIn a retrospective cohort study, patients who underwent isolated TVS at our institution between 2012 and 2020 were screened and followed up to 1 year. We only included those who had all three tests before surgery: ECHO, CMR and RHC. Patients with congenital heart disease, infective endocarditis and those who underwent concomitant valve or pericardial surgery were excluded. The primary outcome was a composite of mortality and congestive heart failure at 1 year. Time-to-event analyses at 1 year and Cox proportional hazards regression analyses were performed.ResultsA total of 60 patients were included (mean age of 60±14 years, 63% women), of whom 67% underwent TV repair. The primary outcome occurred in 16 patients (27%) with a 1-year mortality of 7%. It was associated with ECHO-derived right ventricular (RV) free wall strain and RHC-derived RV systolic and diastolic as well as mean pulmonary pressures. On multivariable Cox regression analysis, only RV systolic and diastolic pressures were significantly associated with the primary outcome at 1 year (HRs=5.9 and 3.4, respectively, pConclusionBaseline invasive haemodynamic assessment could have a strong association with clinical outcomes and help risk-stratify patients undergoing isolated TVS.

Cardiac magnetic resonance imaging plays a central role among multimodality imaging modalities in the assessment, diagnosis, and surveillance of pericardial diseases. Clinicians and imagers should have a foundational understanding of the utilities, advantages, and limitations of cardiac magnetic resonance imaging and how they integrate with other diagnostic tools involved in the evaluation and management of pericardial diseases. This review aims to outline the contemporary magnetic resonance imaging sequences used to evaluate the pericardium, followed by exploring the main clinical applications of magnetic resonance imaging for identifying pericardial inflammation, constriction, and effusion.

Quantitative cardiac magnetic resonance has emerged in recent years as an approach for evaluating a range of cardiovascular conditions, with T(1) and T(2) mapping at the forefront of these developments. Cardiac Magnetic Resonance Fingerprinting (cMRF) provides a rapid and robust framework for simultaneous quantification of myocardial T(1) and T(2) in addition to other tissue properties. Since the advent of cMRF, a number of technical developments and clinical validation studies have been reported. This review provides an overview of cMRF, recent technical developments, healthy subject and patient studies, anticipated technical improvements, and potential clinical applications. Recent technical developments include slice profile and pulse efficiency corrections, improvements in image reconstruction, simultaneous multislice imaging, 3D whole-ventricle imaging, motion-resolved imaging, fat-water separation, and machine learning for rapid dictionary generation. Future technical developments in cMRF, such as B(0) and B(1) field mapping, acceleration of acquisition and reconstruction, imaging of patients with implanted devices, and quantification of additional tissue properties are also described. Potential clinical applications include characterization of infiltrative, inflammatory, and ischemic cardiomyopathies, tissue characterization in the left atrium and right ventricle, post-cardiac transplantation assessment, reduction of contrast material, pre-procedural planning for electrophysiology interventions, and imaging of patients with implanted devices.

This study sought to evaluate the role of cardiac magnetic resonance (CMR) for the quantification of ischemic mitral regurgitation (IMR) and myocardial infarct size (MIS) in patients with ischemic cardiomyopathy (ICM). This study also sought to explore the interaction between IMR severity and MIS and its association with outcomes in patients with ICM.IMR occurs secondary to a disease of the left ventricle and is associated with poor outcomes. The role of CMR for the evaluation and risk stratification of patients with ICM and IMR remains uncertain.Consecutive patients with ICM who underwent baseline CMR were included. MIS was quantified on late gadolinium enhancement imaging as the proportion of left ventricular mass. IMR was quantified with CMR by calculating the mitral regurgitant fraction (MRFraction). Cox proportional hazards models were built to assess the association of IMR and MIS quantification with the combined endpoint of all-cause death or heart transplant.We evaluated 578 patients (mean age: 62 ± 11 years, 76% males). The mean left ventricular ejection fraction was 25 ± 11%, with an MIS of 24 ± 16% and MRFraction of 18 ± 17%. Over a median follow-up time of 4.9 years, 198 (34%) patients experienced death or cardiac transplant. On multivariable analysis, after comprehensive medical risk score, subsequent revascularization, implantable cardioverter-defibrillator insertion, and surgical mitral valve intervention were controlled for, the interaction of IMR severity and MIS emerged as a powerful predictor of adverse outcomes (p = 0.008). For patients with significant IMR (MRFraction: ≥35%), the hazard ratio comparing moderate MIS (15% to 29%) versus small MIS (15%) was 1.51 (0.57 to 3.98), and the hazard ratio comparing large MIS (≥30%) versus small MIS was 5.41 (2.34 to 12.7).Risk associated with IMR is more comprehensively described as an interaction between IMR severity and MIS. Further studies in patients IMR using comprehensive CMR evaluation are needed to verify whether this approach can improve patient selection and procedural outcomes to address IMR.

The objective of the study was to construct a multi-parametric mitral annular calcification (MAC) score using computed tomography (CT) features for prediction of outcomes in patients undergoing mitral valve surgery. We constructed a multi-parametric MAC score, which ranges between 2 and 12, and consists of Agatston calcium score (1 point:1000 Agatston units (AU); 2 points: 1000-3000 AU; 3 points: 3000-5000 AU; 4 points:5000 AU), quantitative MAC circumferential angle (1 point:90°; 2 points: 90-180°; 3 points: 180-270°; 4 points: 270-360°), involvement of trigones (1 point: 1 trigone; 2 points: both trigones), and 1 point each for myocardial infiltration and left ventricular outflow tract extension/involvement of aorto-mitral curtain. The association between MAC score and clinical outcomes was evaluated. The study cohort consisted of 334 patients undergoing mitral valve surgery (128 mitral valve repairs, 206 mitral valve replacements) between January 2011 and September 2019, who had both non-contrast gated CT scan and evidence of MAC. The mean age was 72 ± 11 years, with 58% of subjects being female. MAC score was a statistically significant predictor of total operation time (P0.001), cross-clamp time (P = 0.001) and in-hospital complications (P = 0.003). Additionally, MAC score was a significant predictor of time to all-cause death (P = 0.046). A novel multi-parametric score based on CT features allowed systematic assessment of MAC, and predicted clinical outcomes in patients with mitral valve dysfunction undergoing mitral valve surgery.

Background: Challenges remain in our understanding of implications of right ventricle (RV) dysfunction in heart failure. Cardiac magnetic resonance imaging (CMR) is the reference standard for RV quantification, but has seldomly been studied for this purpose in cardiomyopathy patients. We evaluated the predictors and outcomes of reduced CMR-derived right ventricle function in non-ischemic cardiomyopathy (NICM). Methods: Adult NICM patients undergoing CMR quantifying the RV during 2002-2017 were retrospectively studied. Multivariable linear and Cox proportional hazards regression were used to identify factors associated with reduced RV ejection fraction (RVEF) and adverse outcomes. The primary endpoint was all-cause mortality, heart transplant and/or left ventricular assist device implantation. Results: Amongst 624 NICM patients, mean age was 52.7±15.9 years, 253 (40.5%) were female, and RVEF was 43±13%. Factors independently associated with RVEF (beta-coefficients, P-values) were male (-3.26, P Conclusion: Reduced RVEF was prevalent in NICM patients, and was independently associated with worse prognosis in NICM. Important clinical and CMR factors associated with lower RVEF were identified, as well as the optimal prognostic RVEF thresholds.

Background: The impact of cardiomyopathy on left atrial function is currently unclear. The aim of this study was to assess the predictors of left atrial function in patients with non-ischemic dilated cardiomyopathy (NICM) utilizing cardiovascular magnetic resonance (CMR) assessment. Methods: We evaluated 251 NICM patients who underwent CMR in our study, between 12/2008 - 1/2014. LA volumes were measured by the modified biplane method from 2- and 4-chamber long axis views at end-systole and end-diastole. Left atrial ejection fraction (LAEF) was calculated. Multivariable linear regression was performed to determine significant covariate associations with LA EF. Results: We studied 251consecutive patients (61 % male), mean age of 52.5 ± 15.5 years . The results of the multivariable linear regression are provided in Figure 1. Younger age, female sex, and less myocardial fibrosis were significantly associated with higher LAEF (p=0.008, p= 0.004, and p= 0.031, respectively). Additionally, increasing left ventricular end diastolic volume index (LVEDVi) and left ventricular ejection fraction (LVEF) was significantly associated with increasing LAEF (both with a significance of p Conclusions: In patients with NICM, age, sex, LVEDVi, LVEF, myocardial fibrosis, and LAVi were independently associated with LAEF. Keywords: Nonischemic cardiomyopathy, left atrial ejection fraction, left atrial function, cardiovascular magnetic resonance

Background: Left atrial (LA) size has been shown to be predictive of adverse outcomes in patients with various cardiac conditions. However, the significance of left atrial function (LAF) is not clearly defined in patients with advanced ischemic cardiomyopathy (ICM). We assess the effect of cardiac magnetic resonance imaging (CMR) based LA ejection fraction (LAEF), LA volume index (LAVi) and total LA strain(Las) on outcomes in patients with ICM. Methods: Patients with ICM, who underwent cardiac magnetic resonance (CMR) between January 2002 and January 2017, were included in our study. Clinical characteristics and CMR parameters were collected and analyzed. Maximum and minimum left atrial volume (LAV) and LAEF were calculated using the biplane area-length method. Multi-variable Cox proportional hazards models were then built to test whether LAEF, LAs, and LAVi predict all-cause mortality or time to transplant. The proportionality assumption test and supremum test for functional form were used to verify the model. Results: LA functional data on 656 patients were analyzed. Patients were followed for a median of 1900 days (5.2 years). There were 336 deaths and 17 transplants. LAEF and Las were significant predictors of outcome: HR=0.98, 95% CI [0.97, 0.99], p Conclusion: Left atrial function is a more powerful predictor of adverse outcome than left atrial size and ischemic mitral regurgitation. Further studies are needed to assess impact of treatment on LA function.

Background: Transthoracic echocardiography (TTE) is the first-line imaging modality to evaluate isolated tricuspid regurgitation (TR), however comparisons with magnetic resonance imaging (MRI) measurements have seldomly been studied. We assessed the correlation, discriminative ability and derived a novel TTE-based algorithm using TR and right heart parameters to identify isolated severe TR by MRI. Methods: Isolated TR patients graded at least moderate-to-severe by TTE and undergoing MRI between January 2007-June 2019 were studied. TR and right heart parameters were analyzed by correlation, receiver-operative characteristics analysis and classification and regression tree algorithm for detection of severe TR by MRI (regurgitant volume > 45mL and/or fraction > 50%). Results: In 262 isolated TR patients, 108 (41.2%) had severe TR by MRI. There were moderate correlations and discrimination for most TTE-derived TR parameters and indexed right atrial volume (Pearson r=0.428-0.645) for TR quantification by MRI. This included a mean absolute and percentage difference of +10mL and +19% for regurgitant volume by TTE higher than MRI. However, there were none to modest correlations between TTE-derived right ventricle parameters with MRI-derived TR or right ventricle quantification. Key TTE parameters to identify severe TR by MRI in the decision tree regression algorithm were right atrial volume indexed >47cm 2 /m 2 , then effective regurgitant orifice area >0.45 cm 2 , and finally those with right ventricle free wall strain >-9.5% had the highest risk. Conclusion: TTE-derived TR and right atrial quantification had moderate correlation and discrimination of severe TR by CMR, from which a novel TTE-based decision tree algorithm was derived, while RV correlation was relatively poor between TTE and CMR.

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

BACKGROUND: In a primary prevention screening program of asymptomatic middle-aged subjects, we sought to assess the degree of risk-reclassification provided by traditional risk assessment vs. coronary artery calcification scoring (CACS). METHODS: A total of 1,806 consecutive asymptomatic subjects (age 55 years, 76% men), who underwent comprehensive screening in a primary prevention clinic between 3/2016 and 9/2017 were included. Standard risk factors, C-reactive protein (CRP) and CAC scoring were performed. % 10-year coronary heart disease (CHD) risk was calculated using Reynolds Risk Score (RRS), atherosclerotic cardiovascular disease (ASCVD) score and multiethnic study on subclinical atherosclerosis (MESA) CACS were calculated. % 10-year CHD risk for all scores was categorized as follows: 10%. RESULTS: Mean CRP, RRS, ASCVD and MESA-CACS were 2.1±4.2, 3.7±4, 4.9±6, 4.9±5; 54% had CAC of 0, while 21% had CAC >75th percentile. There was a significant, but modest correlation between MESA-CAC score and (I) RRS (r=0.62) and (II) ASCVD scores (r=0.65, both P

BACKGROUND: Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy with poor prognosis absent appropriate treatment. Elevated native myocardial T(1) and T(2) have been reported for CA, and tissue characterization by cardiac MRI may expedite diagnosis and treatment. Cardiac Magnetic Resonance Fingerprinting (cMRF) has the potential to enable tissue characterization for CA through rapid, simultaneous T(1) and T(2) mapping. Furthermore, cMRF signal timecourses may provide additional information beyond myocardial T(1) and T(2). METHODS: Nine CA patients and five controls were scanned at 3T using a prospectively gated cMRF acquisition. Two cMRF-based analysis approaches were examined: (1) relaxometric-based linear discriminant analysis (LDA) using native T(1) and T(2), and (2) signal timecourse-based LDA. The Fisher coefficient was used to compare the separability of patient and control groups from both approaches. Leave-two-out cross-validation was employed to evaluate the classification error rates of both approaches. RESULTS: Elevated myocardial T(1) and T(2) was observed in patients vs controls (T(1) 1395±121 vs 1240±36.4 ms, p

Background Left ventricular non‐compaction remains a poorly described entity, which has led to challenges of overdiagnosis. We aimed to evaluate if the presence of a thin compacted myocardial layer portends poorer outcomes in individuals meeting cardiac magnetic resonance criteria for left ventricular non‐compaction . Methods and Results This was an observational, retrospective cohort study involving individuals selected from the Cleveland Clinic Foundation cardiac magnetic resonance database (N=26 531). Between 2000 and 2018, 328 individuals ≥12 years, with left ventricular non‐compaction or excessive trabeculations based on the cardiac magnetic resonance Petersen criteria were included. The cohort comprised 42% women, mean age 43 years. We assessed the predictive ability of myocardial thinning for the primary composite end point of major adverse cardiac events (composite of all‐cause mortality, heart failure hospitalization, left ventricular assist device implantation/heart transplant, ventricular tachycardia, or ischemic stroke). At mean follow‐up of 3.1 years, major adverse cardiac events occurred in 102 (31%) patients. After adjusting for comorbidities, the risk of major adverse cardiac events was nearly doubled in the presence of significant compacted myocardial thinning (hazard ratio [HR], 1.88 [95% CI, 1.18‒3.00]; P =0.016), tripled in the presence of elevated plasma B‐type natriuretic peptide (HR, 3.29 [95% CI, 1.52‒7.11]; P =0.006), and increased by 5% for every 10‐unit increase in left ventricular end‐systolic volume (HR, 1.01 [95% CI, 1.00‒1.01]; P =0.041). Conclusions The risk of adverse clinical events is increased in the presence of significant compacted myocardial thinning, an elevated B‐type natriuretic peptide or increased left ventricular dimensions. The combination of these markers may enhance risk assessment to minimize left ventricular non‐compaction overdiagnosis whilst facilitating appropriate diagnoses in those with true disease.

Highlights • Sudden cardiac death (SCD), especially in young athletes, should be avoided. • Current pre-sports screening is based on history/physical exam (insufficient). • ECG is an excellent test for electrically induced SCD but requires expert review. • Screening MRI is the best tool for identifying myocardiopathies/coronary anomalies. • Results of a preliminary population-based study confirm the value of screening MRI., Preventing sudden cardiac death (SCD) in athletes is a primary duty of sports cardiologists. Current recommendations for detecting high-risk cardiovascular conditions (hr-CVCs) are history and physical examination (H&P)-based. We discuss the effectiveness of H&P-based screening versus more-modern and accurate methods. In this position paper, we review current authoritative statements and suggest a novel alternative: screening MRI (s-MRI), supported by evidence from a preliminary population-based study (completed in 2018), and a prospective, controlled study in military recruits (in development). We present: 1. Literature-Based Comparisons (for diagnosing hr-CVCs): Two recent studies using traditional methods to identify hr-CVCs in >3,000 young athletes are compared with our s-MRI-based study of 5,169 adolescents. 2. Critical Review of Previous Results: The reported incidence of SCD in athletes is presently based on retrospective, observational, and incomplete studies. H&P’s screening value seems minimal for structural heart disease, versus echocardiography (which improves diagnosis for high-risk cardiomyopathies) and s-MRI (which also identifies high-risk coronary artery anomalies). Electrocardiography is valuable in screening for potentially high-risk electrophysiological anomalies. 3. Proposed Project: We propose a prospective, controlled study (2 comparable large cohorts: one historical, one prospective) to compare: (1) diagnostic accuracy and resulting mortality-prevention performance of traditional screening methods versus questionnaire/electrocardiography/s-MRI, during 2-month periods of intense, structured exercise (in military recruits, in advanced state of preparation); (2) global costs and cost/efficiency between these two methods. This study should contribute significantly toward a comprehensive understanding of the incidence and causes of exercise-related mortality (including establishing a definition of hr-CVCs) while aiming to reduce mortality.

Background: Cardiac magnetic resonance imaging (CMR) is central to the evaluation of cardiac amyloidosis (CA). Native T1 mapping and extracellular volume (ECV) are novel CMR techniques with evolving utility in cardiovascular diseases including CA. This study aims to meta-analyze the diagnostic and prognostic data of native T1 mapping and extracellular volume (ECV) techniques for assessing CA. Methods: Pubmed, Cochrane and Embase were searched until 31 March 2020 for studies reporting the accuracy of native T1 mapping and ECV for diagnosing CA or predicting all-cause mortality. Area under the receiver-operative characteristics curves (AUC) and hazards ratios (HR) with 95% confidence intervals (95% CI) respectively were pooled using random-effects models and Open-Meta(Analyst) software. Results: Amongst 459 records obtained from the literature search, 41 full-text articles were assessed and 10 studies were eligible totalling 2364 subjects and 1528 patients with confirmed CA. Pooled AUCs (95% CI) for diagnosing CA were 0.924 (0.889-0.959) for native T1 mapping and 0.963 (0.925-1.000) for ECV (Figure panel A/B). Both techniques had similarly high detection rates for AL- and ATTR CA (pooled AUCs of 0.935 and 0.916 for native T1 mapping and 0.980 and 0.952 for ECV). Pooled HRs (95% CI) for predicting all-cause mortality were 1.15 (1.08-1.22) for native T1 mapping as a continuous parameter, 1.19 (1.01-1.40) for ECV as a continuous parameter (Figure panel C/D), and 4.93 (2.64-9.20) for ECV as a binary threshold. Conclusion: Both native T1 mapping and ECV had high diagnostic performance for CA and predicted all-cause mortality after CA. These CMR techniques can play important roles in the multi-modality imaging assessment of CA, including when contrast administration is contraindicated.

Background Cardiac MRI is central to the evaluation of cardiac amyloidosis (CA). Native T1 mapping and extracellular volume (ECV) are novel MR techniques with evolving utility in cardiovascular diseases, including CA. Purpose To perform a meta-analysis of the diagnostic and prognostic data of native T1 mapping and ECV techniques for assessing CA. Study type Systematic review and meta-analysis. Population In all, 3520 patients including 1539 with CA from 22 studies retrieved following systematic search of Pubmed, Cochrane, and Embase. Field strength/sequence 1.5T or 3.0T/modified Look-Locker inversion recovery (MOLLI) or shortened MOLLI (shMOLLI) sequences. Assessment Meta-analysis was performed for all CA and for light-chain (AL) and transthyretin (ATTR) subtypes. Thresholds were calculated to classify native T1 and ECV values as not suggestive, indeterminate, or suggestive of CA. Statistical analysis Area under the receiver-operating characteristic curves (AUCs) and hazards ratios (HRs) with 95% confidence intervals (95% CI) were pooled using random-effects models and Open-Meta(Analyst) software. Results Six studies were diagnostic, 16 studies reported T1 and ECV values to determine reference range, and six were prognostic. Pooled AUCs (95% CI) for diagnosing CA were 0.92 (0.89-0.96) for native T1 mapping and 0.96 (0.93-1.00) for ECV, with similarly high detection rates for AL- and ATTR-CA. Based on the pooled values of native T1 and ECV in CA and control subjects, the thresholds that suggested the absence, indeterminate, or presence of CA were identified as 1073 msec, respectively, for native T1 at 1.5T. Pooled HRs (95% CI) for predicting all-cause mortality were 1.15 (1.08-1.22) for native T1 mapping as a continuous parameter, 1.19 (1.01-1.40) for ECV as a continuous parameter, and 4.93 (2.64-9.20) for ECV as a binary threshold. Data conclusion Native T1 mapping and ECV had high diagnostic performance and predicted all-cause mortality in CA. Level of evidence 1 TECHNICAL EFFICACY STAGE: 2.

Background: Functional mitral regurgitation (MR) grading by echocardiography is often challenging, and cardiac magnetic resonance (CMR) may provide more accurate and reproducible assessment, however optimal CMR thresholds have not been established. We aimed to determine clinically significant thresholds of MR-volume and MR-fraction by CMR in patients with non-ischemic cardiomyopathy (NICM). Methods: All patients having CMR with confirmed NICM between 2001/4/1-2019/3/31 were retrospectively studied. Time to death, heart transplant and/or left ventricular assist device is the primary endpoint, and receiver-operative (ROC) characteristics analyses were used to identify significant cut-points for MR-volume and MR-fraction. Results: Mean MR-volume was 11±12% and MR-fraction 14±13% in 840 NICM patients. C-statistics for the primary endpoint (141 events) were MR-volume 0.629 (95%CI: 0.577-0.691) and MR-fraction 0.594 (95%CI 0.542-0.647). Thresholds of MR-volume≥10mL and MR-fraction≥15% had the highest products of sensitivities and specificities (57.4%, 56.8%; and 54.6%, 63.4% respectively) reflecting elevated risk. MR-volume≥35mL and MR-fraction≥40% were associated the best combination of positive and negative predictive values (40.1%, 84.2%; and 38.4%, 84.6% respectively) representing severe risk. The figure illustrates Kaplan-Meier curves of the primary endpoint, categorized into three subgroups based on aforementioned MR-volume and MR-fraction thresholds. Conclusion: Adverse prognosis are observed when MR-volume≥10mL or MR-fraction≥15%, with increasing risk of adverse outcomes as functional MR severity increased in NICM. The proposed MR thresholds from this study for elevated and severe risk are lower than current valvular regurgitation guidelines, suggesting the need for separate classification schema for functional MR.

Background: Cardiac computed tomography (CT) is emerging as an adjunctive modality to echocardiography in the evaluation of infective endocarditis (IE) and surgical planning. CT studies in IE have, however, focused on its diagnostic rather than prognostic utility, the latter of which is important in high-risk diseases like IE. We evaluated the associations between cardiac CT and transesophageal echocardiography (TEE) findings and adverse outcomes after IE surgery. Methods: Of 833 consecutive patients with surgically proven IE during 5/1/2014-5/1/2019 at Cleveland Clinic, 155 underwent both pre-operative ECG-gated contrast-enhanced CT and TEE. Multivariable analyses were performed to identify CT and TEE biomarkers that predict adverse outcomes after IE surgery, adjusting for EuroSCORE II. Results: CT and TEE were positive for IE in 123 (75.0%) and 124 (75.6%) of patients respectively. CT identified an additional 11% of vegetations, 13% of pseudoaneurysms or abscesses, 5% of dehiscences and 14% of fistulae when TEE was negative. Thirty-day mortality occurred in 3 (1.9%) patients, and composite mortality and/or morbidities in 72 (46.5%). Pseudoaneurysm or abscess detected on TEE was the only imaging biomarker to show independent association with composite mortality and/or morbidities in-hospital, with odds ratio (95%CI) of 3.66 (1.76-7.59), P=0.001. There were 17 late deaths, and both pseudoaneurysm or abscess detected on CT and fistula detected on CT were the only independent predictors of total mortality during follow-up, with hazards ratios (95%CI) of 3.82 (1.25, 11.7), P Conclusion: We identified cardiac CT and TEE features that predicted separate adverse outcomes after IE surgery. Imaging biomarkers can play important roles incremental to conventional clinical factors for risk stratification in patients undergoing IE surgery.

Background: Functional mitral regurgitation (MR) is associated with poor outcomes and the prognostic role of cardiac magnetic resonance imaging (CMR) quantification of secondary MR has rarely been studied. We evaluated the associations between CMR-derived MR-fraction and adverse outcomes in non-ischemic cardiomyopathy (NICM) patients. Methods: We retrospectively studied 840 consecutive NICM patients undergoing CMR during 2001/4/1-2019/3/31. Multivariable Cox proportional hazards regression was performed for MR-fraction and two composite endpoints: primary (time to death, heart transplant and/or left ventricular assist device) and secondary (primary endpoint plus heart failure hospitalizations). Results: The cohort had mean age of 53.0±15.9 years, 319 (38.0) were female, and mean MR-fraction of 14±13% by CMR. There were 141 (16.8%) primary and 223 (26.5%) secondary endpoints over a mean follow-up of 3.6±3.0 years. Multivariable analyses results are shown in the Table. MR-fraction was independently associated with the primary and secondary endpoints with hazards ratios of 1.13 (95%CI 1.07-1.20) and 1.13 (95%CI 1.07-1.19) respectively per 5% increase in MR-fraction. MR-fraction provided stronger prognostic power compared to late gadolinium enhancement (LGE) in both models. Older age and diabetes were independently associated with both composite endpoints, while lower LVEF was independently associated with the secondary endpoint only. Conclusion: CMR quantification of functional MR is a powerful predictor of adverse outcomes and demonstrated stronger associations with poor prognosis compared to LGE and left ventricular remodeling in a large cohort of patients with NICM.

BACKGROUND. Echocardiography is the primary noninvasive technique for left ventricular (LV) strain measurement. MRI has potential advantages, although reference ranges and thresholds to differentia...

Background: Cardiac computed tomography (CT) is emerging as an adjunctive modality to echocardiography in the evaluation of infective endocarditis (IE) and surgical planning. CT studies in IE have, however, focused on its diagnostic rather than prognostic utility, the latter of which is important in high-risk diseases like IE. We evaluated the associations between cardiac CT and transesophageal echocardiography (TEE) findings and adverse outcomes after IE surgery. Methods: Of 833 consecutive patients with surgically proven IE during May 1, 2014 to May 1, 2019, at Cleveland Clinic, 155 underwent both preoperative ECG-gated contrast-enhanced CT and TEE. Multivariable analyses were performed to identify CT and TEE biomarkers that predict adverse outcomes after IE surgery, adjusting for EuroSCORE II (European System for Cardiac operative Risk Evaluation II). Results: CT and TEE were positive for IE in 123 (75.0%) and 124 (75.6%) of patients, respectively. Thirty-day mortality occurred in 3 (1.9%) patients and composite mortality or morbidities in 72 (46.5%). Pseudoaneurysm or abscess detected on TEE was the only imaging biomarker to show independent association with composite mortality or morbidities in-hospital, with odds ratio (95% CI) of 3.66 (1.76–7.59), P =0.001. There were 17 late deaths, and both pseudoaneurysm or abscess detected on CT and fistula detected on CT were the only independent predictors of total mortality during follow-up, with hazards ratios (95% CI) of 3.82 (1.25–11.7), P P =0.007, respectively. Conclusions: We identified cardiac CT and TEE features that predicted separate adverse outcomes after IE surgery. Imaging biomarkers can play important roles incremental to conventional clinical factors for risk stratification in patients undergoing IE surgery.

COVID-19 infection is associated with several cardiac complications with high rates of adverse outcomes. Cardiac imaging has different utility in different clinical scenarios, and the importance of minimizing healthcare worker exposure should be considered. Cardiac imaging should only be ordered if its benefits outweigh its risks, with anticipated changes in acute treatment and outcomes, and no suitable alternative of sufficient adequacy is available. Indications for advanced cardiac imaging for COVID-19 patients in the acute phase are limited, although follow-up imaging in the convalescent stage may provide prognostic importance in recovered COVID-19 patients with positive troponin or decompensated heart failure.

AIM The aim of this study was to investigate whether conventional echocardiographic assessment of right ventricular (RV) systolic function can be improved by the addition of RV strain imaging. Additionally, we also aimed to investigate whether dedicated reading sessions and education can improve echocardiographic interpretation of RV systolic function. METHODS Readers of varying expertise (staff echocardiologists, advanced cardiovascular imaging fellows, sonographers) assessed RV systolic function. In session 1, 20 readers graded RV function of 19 cases, using conventional measures. After dedicated education, in session 2, the same cases were reassessed, with the addition of RV strains. In session 3, 18 readers graded RV function of 20 additional cases, incorporating RV strains. Computer simulations were performed to obtain 230 random teams. RV ejection fraction (RVEF) by cardiac magnetic resonance (CMR) was the reference standard. RESULTS Correlation between RV GLS and CMR-derived RVEF was moderate: Spearman's rho: 0.70, n = 19, P

Background A high proportion of patients with hypertrophic cardiomyopathy (HCM) have evidence of late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR). Objectives This study sought to assess the incremental prognostic utility of LGE in patients with HCM. Methods We studied 1,423 consecutive low-/intermediate-risk patients with HCM (age ≥18 years) with preserved left ventricular (LV) ejection fraction (mean age 66 ± 14 years, 60% men) who underwent transthoracic echocardiography (TTE) (including dimensions and LV outflow tract gradients) and CMR (including LGE as a % of LV mass) at our center between January 2008 and December 2015. The primary composite endpoint was sudden cardiac death (SCD) and appropriate implantable cardioverter-defibrillator discharge. The percent 5-year SCD risk score was calculated. Results The mean 5-year SCD risk score was 2.3 ± 2.0. Mean maximal LV outflow tract gradient (TTE) was 70 ± 55 mm Hg (median 74 mm Hg [interquartile range (IQR): 10 to 67 mm Hg]); indexed LV mass and LGE (both on CMR) were 91 ± 10 g/m2 and 8.4 ± 12% (IQR: 0% to 19%); 50% had LGE on CMR. Of these, 458 were nonobstructive and 965 were obstructive (of which 686 were underwent myectomy). At 4.7 ± 2.0 years of follow-up, 60 (4%) met the composite endpoint. On quadratic spline analysis, LGE ≥15% was associated with increased risk of composite events. In the obstructive subgroup, on competing risk regression analysis, ≥15% LGE (subhazard ratio: 3.04 [95% confidence interval: 1.48 to 6.10]) was associated with a higher rate and myectomy (subhazard ratio: 0.44 [95% confidence interval: 0.20 to 0.76]) was associated with a lower rate of composite endpoints (both p Conclusions In low-/intermediate-risk adult patients with HCM (obstructive, myectomy, and nonobstructive subgroups) with preserved systolic function, %LGE was significantly associated with a higher rate of composite endpoint, providing incremental prognostic utility.

In hypertrophic cardiomyopathy (HCM), adaptive remodeling may affect passive left ventricular (LV) elasticity, myocardial mass, and LV dimensions. However, LV ejection fraction (EF), does not effectively account for the relationship between LV mass and dimensions, especially in heart failure with

Background In patients with suspected coronary artery disease (CAD) who underwent coronary computed tomographic angiography (CCTA), the prognostic value of nonobstructive stenosis is not entirely understood. Aims We sought to assess the long-term incremental prognostic utility of functionally non-significant CAD in patients without known prior CAD who underwent CCTA. Methods We included 2142 consecutive patients (51±14 years, 53% men) without prior documented CAD who underwent CCTA between 2008–2016 (excluding anomalous coronaries and functionally significant CAD). Traditional risk factors were recorded and pretest likelihood of CAD was calculated. All epicardial coronary arteries were classified as follows: No plaque, minimal luminal irregularities ( Results 188 (9%) patients had low, 1712 (80%) had intermediate and 242 (11%) patients had high pre-test likelihood of CAD. 45%, 10%, 52% and 22% had hypertension, diabetes, Dyslipedimia and history of smoking respectively. Breakdown of CAD severity was: 1197 (56%) none, 480 (22%) minimal, 267 (13%) mild and 198 (9%) moderate stenoses. 82 (4%) had noncalcified, 245 (11%) had calcified and 618 (29%) had mixed plaque. 465 (22%) had high-risk plaque features. At 6±3 years, 90 (4%) patients had composite events (68 deaths) and 24 (1%) needed coronary revascularization >90 days post-CCTA. 880 (41%) were on statins post-CCTA. Results of multivariable Cox Survival Analysis are shown in Figure 1A. Kaplan-Meier survival curves for a) more severe CAD and b) high-risk plaque features (vs. not) are shown in Figure 1B and C. Longer-term event rates for increasing CAD were 2.8%, 4.6%, 6% and 9.6%, respectively. Conclusion In mostly low/intermediate risk patients without documented CAD who underwent CCTA, a higher burden of nonobstructive coronary plaque (or presence of high-risk features) provide incremental prognostic value. Initiating statin therapy following detection of plaque on CCTA was associated with improved longer-term freedom from composite events.