Result of the Tri.Fr Trial (Transcatheter Edge-to-Edge Repair in Patients With Isolated Tricuspid Regurgitation)

Coisne A, L'Official G, Dreyfus J, et al.

Echocardiographic Outcomes After Transcatheter Edge-to-Edge Repair in Patients With Isolated Tricuspid Regurgitation: The Tri.Fr Trial.

JACC Cardiovasc Imaging 2025; 18:S1936-878X(25)00531-5; https://doi.org/10.1016/j.jcmg.2025.09.010

This study explored the relationships among tricuspid regurgitation (TR) reduction after tricuspid transcatheter edge-to-edge repair (T-TEER), changes in right-sided heart function, and outcomes. A total of 300 patients (aged 78 ± 5 years; 53.7% women) were enrolled; 152 patients were allocated to the T-TEER + guideline-directed medical therapy (GDMT) group, and 148 were allocated to the GDMT group. Patients in the T-TEER + GDMT group demonstrated a significant decrease in most of parameters of right ventricular (RV) function, whereas patients in the GDMT group exhibited no significant changes in RV metrics at 1 year. The clinical composite score improved progressively with each successive grade of TR reduction. The positive effect of T-TEER on the composite clinical score was observed irrespective of baseline right atrial volume but only in patients with normal RV-pulmonary artery coupling (defined by a tricuspid annular plane systolic excursion-to-systolic pulmonary artery pressure ratio ≥0.40). At 1 year, patients with an improved clinical composite score had a lower right atrial volume index compared with patients whose clinical score remained unchanged or worsened (median 112 mL/m2 [Q1-Q3: 78.0-146 mL/m2] vs median 141 mL/m2 [Q1-Q3: 107-173 mL/m2]; P = 0.004). Although T-TEER can decrease TR severity, its impact on conventional RV function parameters and RV-pulmonary artery coupling remains limited. RV functional recovery has a smaller influence on clinical outcomes at 1 year compared with achieving optimal reduction in TR severity.

Keywords: echocardiography; tricuspid valve; tricuspid regurgitation; structural interventions.

Lay summary: This study looked at whether a minimally invasive tricuspid valve repair (T-TEER) helps patients with severe tricuspid regurgitation. One year after the procedure, patients who received T-TEER had a clear reduction in valve leakage, while those treated with medications alone did not. Improving the leak was strongly linked to better symptoms and overall clinical status. However, the procedure did not lead to major improvements in right-heart pumping function. The benefits of T-TEER were seen mainly in patients whose heart–lung pressure relationship was normal at baseline. Overall, reducing the valve leak—not restoring right-heart function—was the main factor associated with better outcomes.

Sex specific echo thresholds for amyloid identification

Lindqvist P, Venkateshvaran A, Arvidsson S.

RWT/SaVR ratio displays Strong Diagnostic Performance to identify Transthyretin Amyloid Cardiomyopathy in Females: Implications for Sex-Specific Echocardiographic Thresholds.

European Heart Journal - Imaging Methods and Practice, qyaf148, https://doi.org/10.1093/ehjimp/qyaf148

The study assessed the diagnostic accuracy of echocardiographic and echocardiographic red flags in women to differentiate transthyretin cardiomyopathy ATTR-CM from left ventricular hypertrophy (LVH).

In a cohort of 62 female patients with interventricular septal thickness of >12 mm, divided equally into well-defined ATTR-CM (n=31) and age-matched LVH, ATTR-CM displayed higher relative wall thickness (RWT), higher values for relative apical sparing (RELAPS) and lower S-wave in lead aVR (SaVR) than LVH. Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) did not differ between groups. RWT/SaVR ratio displayed stronger diagnostic performance to identify ATTR-CM (AUC=0.97) when compared with RELAPS (AUC=0.83) and RWT (AUC=0.82). Further, RELAPS demonstrated lower, and SaVR higher optimal diagnostic cut-offs than those previously published in predominant male cohorts.

In a well-characterized, single-center, female population with hypertrophied left ventricles, RWT/SaVR outperformed conventional echocardiographic red-flags and shows promise for diagnosing ATTR-CM. Validation in larger prospective cohorts is warranted.

Keywords: echocardiography, amyloid cardiomyopathy, sex disparities.

Lay summary: This study examined whether common heart-imaging clues used to detect transthyretin cardiomyopathy (ATTR-CM) work as well in women as they do in men. Researchers compared heart ultrasound and ECG measurements in 62 women with thickened heart walls—half with ATTR-CM and half with other causes of left ventricular hypertrophy (LVH). Women with ATTR-CM had thicker, more concentric heart walls and a weaker electrical signal (S-wave) on ECG. A combined measure (RWT/SaVR ratio) was the best indicator of ATTR-CM, performing better than standard red-flag markers. Importantly, the optimal cut-off values differed from those reported in mostly male populations, suggesting women may need sex-specific diagnostic thresholds. Larger studies are needed to confirm these findings.

Point of Care cardiac ultrasound for screening of cardiovascular disease in pregnant women

Bhatti S, Naz S, Gurmani S, et al.

Point-of-Care Ultrasound versus Routine Transthoracic Echocardiography for Screening of Cardiovascular Disease in Pregnant Women.

European Heart Journal - Imaging Methods and Practice, qyaf110, https://doi.org/10.1093/ehjimp/qyaf110

The Prospective Pakistan Registry of Echocardiographic Screening in Asymptomatic Pregnant Women (PRESAP) is a registry designed for the echocardiographic screening of structural heart disease (SHD). It offers a unique opportunity to compare the effectiveness of point-of-care ultrasound (POCUS) versus routine transthoracic echocardiography (TTE) in this population. Between February 2023 and March 2024, pregnant women without known heart disease were enrolled in the PRESAP registry. Participants underwent a limited echocardiogram, using either POCUS or TTE. The primary outcome was the detection of abnormal findings, including left ventricular systolic dysfunction (LVSD), valvular heart disease (VHD), and congenital heart disease (CHD). Matching cohorts were created using propensity score matching, based on demographic factors, comorbid conditions, and gestational history. Among 18,401 patients, 9,681 (52.6%) underwent POCUS. The 1:1 propensity-matched cohort included 4,177 patients in each arm. Abnormal echocardiographic findings were detected in 4.4% (185) of the TTE group and 3% (124) of the POCUS group (p<0.001). VHD (1.3% vs. 1.1%; p=0.416) and CHD (0.4% vs. 0.6%; p=0.093) were detected at similar rates by both methods, while LVSD was more frequently identified by TTE compared to POCUS (2.8% vs. 1.5%; p<0.001). POCUS may be considered as an alternative to TTE for screening for SHD in asymptomatic pregnant women, particularly in resource-limited settings. TTE was superior for LVSD, POCUS was equally effective in identifying valvular and congenital heart disease.

Keywords: portable echocardiography, pregnancy, structural heart disease, valvular, congenital.

Lay summary: The PRESAP study in Pakistan looked at the best way to screen pregnant women without known heart problems for structural heart disease (SHD). They compared two types of heart ultrasound: the standard, detailed transthoracic echocardiography (TTE) and a simpler, portable method called Point-of-Care Ultrasound (POCUS). Researchers enrolled over 18,000 pregnant women, about half of whom received POCUS. They found that TTE detected abnormal heart findings (4.4%) more often than POCUS (3%). The main difference was in finding a weakened heart muscle, or Left Ventricular Systolic Dysfunction (LVSD), which TTE was significantly better at detecting. However, both POCUS and TTE were equally effective at identifying valvular heart disease (VHD) and congenital heart disease (CHD). The study concludes that POCUS is a viable alternative to TTE for screening asymptomatic pregnant women, especially in places where resources might be limited, as it performs just as well in finding valve and congenital issues.

Deep learning based real-time Global Longitudinal Strain improves echocardiographic workflow efficiency

Holmstrøm V, Smistad E, Stølen S, et al.

Real-Time Global Longitudinal Strain During Echocardiography: A Deep Learning Platform for Improved Workflow.

J Am Soc Echocardiogr 2025; 38:1041-1051; https://doi.org/10.1016/j.echo.2025.08.015

This study aimed to evaluate the real-time deep learning platform for global longitudinal strain (GLS) measurements during image acquisition and to assess whether it can improve image quality metrics relevant to strain analyses. Authors developed a novel integrating deep-learning platform for fully automated real GLS analysis directly into the echocardiographic acquisition which was tested on 50 patients and compared to convention workflow and strain assessment. Results indicated that deep-learning based real-time GLS measurements were feasible in 94% and reduced the time required to obtain measurements by more than half compared to conventional workflow.  The correlation between methods was excellent (correlation coefficient r=0.94), as well as the agreement between deep-learning based GLS measurements and conventional workflow (bias of −1.3 strain units and limits of agreement ranging from −3.5 to 0.8 strain units). The deep-learning platform also improved image quality metrics essential for strain analyses. The study concludes that the novel deep-learning platform for real-time GLS measurements demonstrates high feasibility, strong agreement with experts’ reference measurements, and improved time efficiency. The author believe that this platform has a potential to improve strain imaging workflow in the daily clinical practice.

Keywords: echocardiography, global longitudinal strain, deep learning, artificial intelligence.

Lay summary: A new AI-based platform was tested for measuring the function of the left ventricle, aiming to replace today's manual measurements. This advanced deep learning system automatically analyzes heart images in real-time, making the diagnostic process twice as fast. Since the automated measurements were shown to be reliable, precise, and comparable to existing methods, doctors can now perform quicker heart exams without compromising accuracy. This innovation is poised to greatly boost efficiency in daily echocardiography lab operations.

Ultrasound shear wave elastography detects myocardial fibrosis  

Petrescu A, Cvijic M, Wouters L, et al.

Ultrasound shear wave elastography for detection of myocardial fibrosis.

Eur Heart J Cardiovasc Imaging 2025; 26:1537-1545; http://doi.org/10.1093/ehjci/jeaf200

Echocardiographic shear wave (SW) elastography is an emerging approach for measuring myocardial stiffness in vivo. SWs occur after mechanical excitation of the myocardium, e.g. after mitral valve closure, and their propagation velocity is directly related to myocardial stiffness. This study aimed to evaluate whether SW velocities can distinguish between replacement and interstitial fibrosis. The study included 22 patients with hypertrophic cardiomyopathy, 30 heart transplant and 37 age-matched healthy volunteers, studied by high-frame echocardiography. Results demonstrated that shear wave velocity can distinguish between patients without fibrosis as well as between replacement and interstitial fibrosis. Shear wave velocities below 6 m/s could reliably identify without fibrosis [sensitivity 90%, specificity 90%, area under the curve = 0.95), while shear wave velocities of 8.1 m/s could distinguish replacement fibrosis from interstitial fibrosis (sensitivity 69%, specificity 100%, AUC = 0.92). The study concludes that shear wave velocities after mitral valve closure can distinguish between normal and pathological myocardium and variate with the fibrosis burden of the myocardium.

Keywords: echocardiography, high-frame echocardiography, shear wave velocity, fibrosis.

Lay summary: This study tested whether new echocardiographic method called shear wave elastography can be used to identify the fibrosis in the heart. The authors compared the healthy volunteers and the patients with hypertrophic cardiomyopathy and heart transplant patients who had with different degree of fibrosis in the heart. Patients who had fibrosis in the heart had higher values of shear wave velocities. The study found that lower shear wave velocities (below 6.0 m/s) were accurate in identifying patients without fibrosis. This new method could allow doctors to accurately and early detect fibrosis using echocardiography, potentially reducing the need for additional examinations.

Tracking LVOT-VTI Change to Improve Risk Stratification in Transthyretin Cardiac Amyloidosis

Venneri L, Aimo A, Porcari A, et al.

Artificial intelligence-based echocardiographic assessment for monitoring disease progression in transthyretin cardiac amyloidosis.

Eur J Heart Fail 2025; https://doi.og/10.1002/ejhf.70073

This study provides a valuable large-cohort evaluation of transthyretin cardiac amyloidosis (ATTR-CM), a rare infiltrative cardiomyopathy for which reliable tools to monitor disease progression remain limited. A total of 752 patients underwent echocardiography at diagnosis and again after 12 ± 1 months, with measurements obtained through a fully automated platform (Us2.ai) to ensure consistent Doppler assessment. The central observation is that the change in LVOT-VTI over one year—rather than its baseline value—was independently associated with subsequent mortality. Even modest reductions were informative: a decline of ≥5% identified patients with worse survival (HR 1.41; 95% CI 1.13–1.76). In comparison, commonly used parameters such as LVEF, stroke volume, and GLS did not show similar prognostic performance. These findings suggest that LVOT-VTI, a simple and widely available Doppler measure, may capture early haemodynamic deterioration more effectively than traditional indices in ATTR-CM. Although limited by its single-centre design and reliance on automated processing, the study supports incorporating longitudinal LVOT-VTI assessment into follow-up strategies for ATTR-CM, offering a practical approach to refining risk stratification in a rare disease.

Keywords: ATTR; Artificial intelligence; Cardiac amyloidosis; Disease progression; Echocardiography; Prognosis; Risk stratification; Stroke volume; Transthyretin amyloid cardiomyopathy.

Lay summary: Transthyretin cardiac amyloidosis is an uncommon heart disease where abnormal protein deposits gradually affect how the heart works. This study examined a simple Doppler measurement called LVOT-VTI, which reflects how much blood the heart pumps forward. It was measured at diagnosis and again about one year later. The key finding was that the change in this value over the year provided clearer information about future risk than the starting value alone. Patients whose LVOT-VTI decreased by 5% or more during the first year had a higher chance of dying in the following years. Other common echocardiographic measurements were less helpful for predicting this risk. Regularly tracking LVOT-VTI may help identify patients whose condition is worsening earlier, allowing for closer follow-up and more informed clinical decisions.

Left Atrial Functional Impairment Predict Incident Atrial Fibrillation in Patients with HFrEF

Stanchev A, Christensen J, Davidovski FS et al.

Measures of left atrial function and risk of incident atrial fibrillation in patients with heart failure with reduced ejection fraction.

Eur Heart J Cardiovasc Imaging 2025; 26:1549-1556; https://doi.org/10.1093/ehjci/jeaf205

This multicentre observational study examined whether echocardiographic indices of left atrial (LA) function can anticipate new-onset atrial fibrillation (AF) in patients with heart failure with reduced ejection fraction (HFrEF). The cohort included 452 clinically stable outpatients in sinus rhythm (mean age 65.5 years, 70% men) who underwent a detailed LA evaluation, including emptying fraction (LAEF), peak atrial longitudinal strain (PALS), and peak atrial contractile strain (PACS). Over a median follow-up of 9.4 years, 118 patients (26%) developed AF. Patients who developed AF had more advanced atrial remodelling at baseline—larger indexed LA volumes and markedly impaired functional parameters. All three LA measures were independently associated with incident AF: each 1% reduction in LAEF, PALS, and PACS increased AF risk (HR 1.03, 1.06, and 1.07, respectively). Notably, the prognostic contribution of LAEF and PACS differed by sex and by the presence of significant valve disease, indicating that the substrate underlying atrial dysfunction modulates arrhythmic vulnerability. Overall, the work reinforces the concept that LA function—not merely chamber size—captures clinically relevant atrial disease in HFrEF. Incorporating strain-based indices and LAEF into routine assessment could help identify patients who merit closer rhythm surveillance well before AF becomes clinically manifest.

Keywords: Left atrial function; LA emptying fraction; PALS; PACS; Echocardiography; Atrial fibrillation; Heart failure with reduced ejection fraction; Atrial remodeling.

Lay summary: People with heart failure and reduced ejection fraction often develop atrial fibrillation (AF), but it can be difficult to predict who will develop it. This study followed 452 patients who were in sinus rhythm at the start and evaluated how their left atrium was working using echocardiography. During nearly ten years of follow-up, about one quarter of patients developed AF. Those who later developed AF already showed reduced atrial function at the first examination, even when the atrium was not markedly enlarged. These findings suggest that looking at how the left atrium works, rather than assessing size alone, may help identify patients at higher risk of AF and allow for more careful monitoring over time.

Indexed Mitral Annular Disjunction Shows Sex-Specific Associations with Arrhythmic Risk in Mitral Valve Prolapse

Cristin L, Tastet L, Jhawar R et al.

Sex-Based Differences in Mitral Annular Disjunction Severity and Arrhythmic Risk in Mitral Valve Prolapse.

J Am Soc Echocardiogr 2025; S0894-7317(25)00517-6; https://doi.org/10.1016/j.echo.2025.08.026

This study evaluated 682 patients with mitral valve prolapse (MVP) to explore how mitral annular disjunction (MAD) and its indexed length (iMAD) relate to arrhythmic risk in men and women. MAD was identified using standard parasternal long-axis imaging and was present in 41% of the cohort (mean length 8.1 ± 3.0 mm; median iMAD 4 mm). Women showed a higher prevalence, while men had longer absolute lengths; however, this difference disappeared once measurements were indexed to body surface area. What emerges is a clear sex-related pattern. In men, an iMAD ≥4 mm was independently associated with arrhythmic MVP (OR 2.2; 95% CI 1.1–4.2) and with severe arrhythmic events (OR 1.24; P = .03). In women, arrhythmic risk was more closely linked to bileaflet prolapse and mechanical dispersion, pointing toward a different contribution of myocardial mechanics. Mediation analysis reinforced this divergence: in men, a substantial portion of the arrhythmic effect of bileaflet MVP was explained by iMAD, whereas in women the association appeared to act directly. A relevant limitation is the limited use of cardiac MRI, so MAD characterization relied mainly on echocardiography. Overall, the study suggests that indexing MAD and recognizing sex-specific patterns may refine arrhythmic risk assessment in MVP and warrants further exploration of underlying mechanisms.

Keywords: Mitral valve prolapse; Mitral annular disjunction; Indexed MAD; Arrhythmic risk; Sex differences; Echocardiography; Ventricular arrhythmias.

Lay summary: Mitral valve prolapse (MVP) is a valve abnormality that affects a minority of individuals and may, in some cases, be associated with heart rhythm disturbances. This study focused on a structural feature known as mitral annular disjunction (MAD), which can be identified on a standard echocardiogram as a small separation between the mitral valve ring and the underlying heart muscle. The results showed that the implications of MAD differ between men and women. In men, a larger, body-size–adjusted separation was more often associated with rhythm abnormalities. In women, the risk of arrhythmias appeared to be influenced instead by the specific prolapse pattern and by how uniformly the heart muscle contracts. These findings indicate that MVP is not a uniform condition and that sex-specific characteristics may help refine the evaluation of rhythm risk and guide follow-up strategies.

Cardiac magnetic resonance is a valid first-line, non-invasive diagnostic modality to detect ischemic heart disease in patients with heart failure

Güder G, Reiter T, Bauer WR, et al.

Cardiac Magnetic Resonance Imaging vs Coronary Angiography as Primary Strategy in Newly Diagnosed Heart Failure.

JACC Heart Fail 2025; 13:102528; https://doi.org/10.1016/j.jchf.2025.102528

This multicenter randomized trial analyzed 229 patients with new-onset heart failure with reduced ejection fraction (HFrEF) to compare the diagnostic performance of cardiac magnetic resonance imaging (CMR) versus percutaneous invasive coronary angiography (CATH) in identifying ischemic heart disease (IHD) as the primary cause of heart failure. Patients underwent baseline evaluation with either CMR or CATH first, then the other modality. CMR was completed in 95 patients and CATH in 108 patients. CATH was sufficient to diagnose or exclude IHD in 100% of cases, whereas CMR was sufficient in 80% (P < 0.001). Sensitivity for IHD diagnosis was high and similar between CATH (91%) and CMR (90%), but specificity was significantly higher for CATH (98%) than for CMR (74%, P < 0.001). Importantly, a CMR-first strategy could potentially avoid 45% of invasive CATH procedures without missing critical coronary interventions. The low number of false negative results within the CMR group suggests that very few patients with an ischemic origin would have been missed. Further, this modality additionally provided diagnostic insights beyond ischemia, including nonischemic aetiologies. Though CATH remains superior in specificity, CMR is a valid first-line, non-invasive diagnostic modality with comparable sensitivity for ischemic heart failure, and its wider use could safely decrease the number of invasive procedures.

Keywords: cardiac magnetic resonance, percutaneous coronary angiography, heart failure, ischemic heart disease, randomized clinical trial.

Lay summary: Researchers conducted a randomized trial in 229 patients newly diagnosed with heart failure characterized by reduced ejection function. They compared invasive coronary angiography with CMR imaging for diagnosing ischemic cardiomyopathy. The study found that CMR had a similar ability to detect ischemic heart disease but with lower specificity, and its use as the first diagnostic step could reduce the need for invasive angiography by nearly half without missing essential coronary interventions. This strategy also provides broader diagnostic information helping to uncover non-ischemic causes of heart failure.

Trimetazidine effect on myocardial efficiency in carriers of a hypertrophic cardiomyopathy gene variants

Van Driel BO, Schoonvelde SAC, Borodzicz-Jazdzyk S, et al.

Effect of trimetazidine dihydrochloride therapy on myocardial external efficiency in pre-clinical individuals with a hypertrophic cardiomyopathy pathogenic variant: results of the ENERGY trial.

J Cardiovasc Res 2025; 121:1917–1928. https://doi.org/10.1093/cvr/cvaf120

This double-blind, placebo-controlled randomized clinical trial included 40 genotype-positive carriers of pathogenic or likely pathogenic variants in the MYBPC3 or MYH7 genes who did not have a hypertrophic cardiomyopathy phenotype. The study tested whether trimetazidine (TMZ) treatment improved myocardial external efficiency (MEE) compared to placebo. The primary endpoint was the change in MEE measured by PET/CT and cardiac magnetic resonance imaging. After 8 weeks, TMZ did not significantly improve MEE compared to placebo (difference −0.44%; 95% CI, −2.86 to 1.99; P=0.68), but slightly increased peak oxygen uptake after baseline adjustment (6.4% difference; 95% CI, −3 to 16; P=0.04). TMZ was well tolerated with no serious adverse events. Left ventricular ejection fraction, end-diastolic and end-systolic volumes, and wall thickness did not differ significantly between groups at baseline or follow-up. Overall, the imaging data confirmed that TMZ did not modify cardiac structural or functional parameters in this genotype-positive phenotype-negative cohort after 8 weeks.

Keywords: hypertrophic cardiomyopathy, trimetazidine, myocardial external efficiency, cardiac magnetic resonance; randomized clinical trial.

Lay summary: Researchers treated 40 individuals carrying genetic variants for hypertrophic cardiomyopathy, but who had not yet developed heart muscle thickening. They tested whether trimetazidine, a metabolic drug, improved the heart muscle’s energy efficiency in comparison to placebo. The eight-week treatment did not improve the heart’s energy efficiency but slightly improved exercise capacity. These findings suggest that this drug may not reverse early heart muscle energy problems caused by genetic variants.

LGE pattern and location refines arrhythmic risk stratification in nonischaemic cardiomyopathy

Guaricci AI, Carrabba N, Romano SM, et al.

Redefining the risk of major arrhythmic events in non-ischaemic cardiomyopathy: insights from the DERIVATE-NICM study.

Eur Heart J Cardiovasc Imaging 2025; 26:1609-1619; https://doi.org/10.1093/ehjci/jeaf198

The study assessed the prognostic value of a new cardiac magnetic resonance (CMR) score based on late gadolinium enhancement (LGE) pattern distribution in non-ischaemic cardiomyopathy (NICM) patients enrolled in the DERIVATE registry. Among 1384 NICM patients with chronic heart failure and left ventricular ejection fraction (LVEF) <50%, major adverse arrhythmic cardiac events (MAACEs) during a median follow-up of 959 days occurred in 128 (9.2%) patients. In the multivariate analyses, male gender [hazard ratio (HR): 1.605 (95% confidence interval, CI: 1.051-2.451); P = 0.028], LVEF per point % [HR: 0.977 (95% CI: 0.961-0.993); P = 0.005] and presence and location of midwall LGE [weighted HR: 1.066 (95% CI: 1.045-1.086), P < 0.001] were independent predictors of MAACE. A multi-parametric CMR-weighted predictive-derived score (DERIVATE Risk Score 2.0) provided a higher additional prognostic value vs. transthoracic echocardiography-LVEF cut-off of 35% when compared with the previous published DERIVATE Risk Score 1.0 with a net reclassification improvement of 54.52% (95% CI: 36.52-72.52%; P < 0.001). In conclusion, the presence of midwall LGE, but also the location of scar, confers an added and independent MAACE risk to a large NICM population influencing the choice of treatment.

Keywords: hypertrophic cardiomyopathy, trimetazidine, myocardial external efficiency, cardiac magnetic resonance; randomized clinical trial.

Lay summary: This study aimed to better predict serious heart rhythm problems (like sudden cardiac arrest) in patients with non-ischaemic cardiomyopathy (NICM), i.e. heart failure not caused by blocked arteries. The presence and specific location of myocardial scars (also named late gadolinium enhancement) at cardiac magnetic resonance were the strongest independent predictors of major adverse heart events. The Authors also created a new scoring system, the DERIVATE Risk Score 2.0, which incorporates this scar information and outperformed previous risk scores.

CMR differentiation between veteran athletes and mild dilated cardiomyopathy

Javed W, Tomoaia R, Farooq M, et al.

Cardiovascular magnetic resonance to differentiate veteran athlete's heart with cavity dilatation and mild dilated cardiomyopathy.

Eur Heart J Cardiovasc Imaging 2025; 26:1762-1770; https://doi.org/10.1093/ehjci/jeaf234

This study investigated the distribution and patterns of myocardial fibrosis on cardiovascular magnetic resonance (CMR) in athletes with left ventricular (LV) dilatation compared to mild dilated cardiomyopathy (DCM) patients. Of 113 participants (64 veteran athletes and 49 mild DCM patients), athletes with fibrosis demonstrated a greater prevalence of inferolateral fibrosis (87.5% vs. 50.0%, P = 0.002), whereas inferoseptal fibrosis was more common in mild DCM patients (45.8% vs. 9.4%, P = 0.002). Native T1 (1249.0 ± 38.1 vs. 1308.3 ± 47.1 ms, P < 0.001) and extracellular volume (ECV) (22.0 ± 2.1 vs. 25.9 ± 3.5%, P < 0.001) were lower in athletes. Athletes had greater right ventricular end-diastolic volume indexed to body surface area (RVEDVi) (121.0 ± 14.3 vs. 97.6 ± 25.2%, P < 0.001), myocardial perfusion reserve (MPR) (3.65 ± 1.30 vs. 2.76 ± 0.92, P < 0.001), and stress myocardial blood flow (MBF) (2.09 ± 0.70 vs. 1.62 ± 0.66, P < 0.001) than mild DCM patients. On receiver-operator curve analysis, native T1 [area under the curve (AUC) 0.89, P < 0.001], ECV (AUC 0.85, P < 0.001), RVEDVi (AUC 0.81, P < 0.001), and stress MBF (AUC 0.68, P = 0.002) were able to differentiate between groups. In conclusion, septal fibrosis is rare amongst veteran athletes and other parameters (native T1, ECV, and RVEDVi) can help discrimination from dilated cardiomyopathy.

Keywords: hypertrophic cardiomyopathy, trimetazidine, myocardial external efficiency, cardiac magnetic resonance; randomized clinical trial.

Lay summary: This study investigated how to distinguish a healthy, enlarged heart in veteran athletes from an enlarged heart caused by early-stage dilated cardiomyopathy (DCM), using cardiac magnetic resonance (CMR) imaging. The key difference lay in the scar's location: athletes with fibrosis typically showed it on the inferolateral wall, while DCM patients more often displayed fibrosis in the interventricular septum. The study also showed athletes had healthier heart tissue properties, indicated by lower values for MRI markers like Native T1 and ECV, better heart blood flow reserve, and a larger right ventricular chamber. In conclusion, the location of scar tissue (septal involvement suggests DCM) combined with these tissue markers (Native T1, ECV) is highly effective for doctors to accurately determine whether an enlarged heart is due to athletic training or serious disease.

Photon-counting detector computed tomography is a promising non-invasive imaging modality for the diagnostic and prognostic assessment of acute myocarditis

Gkizas C, Longere B, Sliwicka O, et al.

Photon-counting CT-derived extracellular volume in acute myocarditis: Comparison with cardiac MRI.

Diagn Interv Imaging 2025; 106:255–263; https://doi.org/10.1016/j.diii.2025.03.001

This retrospective comparative study assessed the feasibility and accuracy of extracellular volume (ECV) quantification using dual-source photon-counting detector computed tomography (PCD-CT) with late iodine enhancement in suspected acute myocarditis, using cardiac MRI as the reference standard. Thirty-two patients (mean age 35.9 years; 59% male) with clinical suspicion of myocarditis underwent coronary CT angiography with first-generation PCD-CT and comprehensive cardiac MRI within 24 hours. ECV was calculated from iodine maps on late enhancement PCD-CT images and compared to MRI-derived ECV based on the Lake Louise 2018 criteria. Mean global ECV did not differ significantly between PCD-CT (29.4%) and MRI (30.0%) (p = 0.69). ECV-CT was higher in MRI-confirmed myocarditis (31.65%) than in patients without myocarditis (25.6%) (p < 0.01), correlated strongly with MRI late gadolinium enhancement mass (r = 0.82) and with segmental ECV (basal r = 0.95; mid-ventricular r = 0.91). An ECV-CT threshold of 26.9% yielded an AUC of 0.95 for myocarditis diagnosis, with low mean radiation dose (96 mGy·cm). These findings support PCD-CT as a feasible, accurate, and low-dose alternative to MRI for ECV quantification in acute myocarditis.

Keywords: myocarditis; extracellular volume; photon-counting CT; cardiac MRI; late iodine enhancement.

Lay summary: This study tested a new CT technology, photon-counting detector CT, to measure heart tissue changes in people with suspected acute myocarditis. The CT method gave results almost identical to those from MRI, the current gold standard, and detected abnormal tissue in myocarditis patients with high accuracy, using low radiation doses. This suggests it could be a useful alternative for diagnosing and monitoring myocarditis in patients presenting with chest pain.

After left main PCI, CCTA-guided follow-up improves clinical outcomes vs symptoms- or ischemia- driven care

D’Ascenzo F, Cerrato E, De Filippo O, et al.

Computed Tomography Angiography or Standard Care After Left Main PCI?

J Am Coll Cardiol 2025; 86:1724-1734; https://doi.org/10.1016/j.jacc.2025.07.060

The study aimed to assess whether CCTA-guided follow-up improves clinical outcomes vs symptoms- or ischemia- driven care after left main (LM) PCI. This study is a randomized open-label trial, named PULSE, and enrolled 606 patients treated with PCI for unprotected LM disease; the patients were randomized 1:1 to CCTA at 6-months post-PCI or standard of care. The primary endpoint, a composite of all-cause death, spontaneous myocardial infarction (MI), unstable angina, or stent thrombosis at 18 months, occurred in 36/303 patients in the CCTA arm and 38/303 patients in the standard of care arm (11.9 vs 12.5%, p=0.8). However, compared with the control arm, the CCTA arm showed a reduced risk of spontaneous MI (0.9% vs 4.9%; HR: 0.26; 95% CI: 0.07-0.91; P = 0.004) and an increased risk of imaging-triggered target-lesion revascularization (TLR) (4.9% vs 0.3%; HR: 7.7; 95% CI: 1.70-33.7; P = 0.001), whereas clinically driven TLR rates were similar (5.3% vs 7.2%; HR: 0.74; 95% CI: 0.38-1.41; P = 0.32). Routine CCTA after LM PCI did not reduce the composite primary endpoint, but was associated with fewer spontaneous MIs and more imaging-triggered revascularizations.

Keywords: CCTA, PCI, left main PCI, prognosis, follow-up post-PCI.

Lay summary: In patients with unprotected LM disease treated with PCI it was unclear whether the long-term surveillance should be based on symptoms and ischemia detection or on routine follow-up coronary angiography. This study is the first randomized trial to demonstrate a statistically significant reduction in spontaneous MI in the CCTA surveillance arm compared to the standard of care arm, although the composite outcome of MACE at 18 months was not reduced in the CCTA arm. The primary end-point of MACE reduction was not achieved maybe due to the short follow-up timeframe of 18-months, since the neo-atherosclerosis-related events, phenomena are known to occur later with second-generation DES. In contrast, the spontaneous MIs were reduced due to the precise non-invasive assessment of in-stent-restenosis and neo-atherosclerosis with CCTA; among those with obstructive CCTA findings, repeated PCI was performed in 71% of LM cases. The CCTA-based surveillance markedly reduced the occurrence of spontaneous MI, suggesting that this approach may be useful in selected high-complexity patients and intervention.

Photon-counting detector CT with late iodine enhancement provides myocardial extracellular volume (ECV) measurements in excellent agreement with CMR

Klambauer K, Biondo A, Klotz E, et al.

Photon-counting detector computed tomography compared with cardiac magnetic resonance imaging for myocardial extracellular volume quantification in spontaneous coronary artery dissection

Sci Rep 2025; 15:39923; https://doi.org/10.1038/s41598-025-23777-3

In this single-centre prospective study, 20 patients with spontaneous coronary artery dissection (27 scans) underwent late iodine enhancement photon-counting CT (LIE PCD-CT) to quantify global and lesion myocardial ECV, with 13 patients (15 scans) also undergoing paired CMR with T1-mapping–derived ECV. Global ECV_CT averaged 28.5 ± 5.3%, and lesion ECV_CT was markedly higher at a median 45.2% (IQR 44.2–46.8), with a strong correlation between global ECV_CT and relative lesion volume (Spearman r = 0.94, P < 0.001). In the paired CT–CMR subgroup, agreement for global ECV was excellent: 28.0 ± 5.2% (CT) vs 29.3 ± 4.2% (CMR), mean difference 1.4% (limits of agreement −4.2% to 7.0%; P = 0.085). Lesion ECV_CT (45.2%) was virtually identical to ROI-based lesion ECV_CMR (45.0%), whereas segment-based CMR analysis underestimated lesion ECV (median 36.0%). ROC analysis showed global ECV_CT accurately identified very small lesion volumes (<5% and <10% of LV myocardium; AUC 0.96–1.0). The authors conclude that LIE PCD-CT enables robust, quantitative ECV mapping with close agreement to CMR and may serve as a practical alternative where CMR is unavailable or contraindicated, while adding only ~5 minutes and modest radiation dose to a standard CCTA protocol.

Keywords: photon-counting; CT, CMR, extracellular volume, late iodine enhancement, spontaneous coronary artery dissection, myocardial injury.

Lay summary: Spontaneous coronary artery dissection is an important cause of myocardial infarction in younger, often otherwise healthy patients, but the extent of heart muscle damage can be difficult to assess. This study tested a new CT technology (photon-counting CT) that can create “tissue maps” of the heart muscle after contrast injection, and compared it with the current gold-standard test, cardiac MRI. The CT-based extracellular volume measurements closely matched MRI results for both the overall heart muscle and the injured areas, and they were able to detect even very small scars. Because the CT scan can be done quickly, alongside a routine coronary CT angiogram, and is easier to perform in patients who cannot have MRI, this technique could become a useful alternative for assessing and monitoring heart muscle injury in spontaneous coronary artery dissection and similar conditions.

In patients with bicuspid aortic valve stenosis, transcatheter aortic valve implantation may present stent frame under-expansion, which does not affect valve haemodynamic or leaflet thickening

Tirado Conte G, Arslani K, Zaid S, et al, et al.

Stent frame deformation of self-expanding transcatheter heart valves in bicuspid aortic stenosis and impact on valve performance

Eur Heart J Cardiovasc Imaging 2025; 26:1842-1851; https://doi.org/10.1093/ehjci/jeaf195

In transcatheter aortic valve implantation (TAVI) for native bicuspid AS, reduced stent frame expansion is a concern due to a elliptic valve anatomy compared to tricuspid valves. This multi-centre registry included patients with bicuspid AS who underwent TAVI using the self-expanding Evolut™ transcatheter heart valve and who had pre- and post-TAVI CT. Stent frame expansion and ellipticity were assessed at the inflow (nodes 0-1) and leaflet level (nodes 5-6).  Among 175 patients included, the inflow level of the Evolut THV had greater stent frame under-expansion (79.9% ± 6.7% vs. 95.4% ± 3.1% and P < 0.001) and ellipticity (1.3 ± 0.3 vs. 1.2 ± 0.1 and P < 0.001) compared to the leaflet level. Leaflet level expansion was unaffected by expansion or ellipticity at the inflow level; however, leaflet level ellipticity increased significantly with inflow under-expansion <75% (P = 0.002) and inflow ellipticity ≥1.3 (P < 0.001). Neither inflow under-expansion nor ellipticity impacted hemodynamic valve performance (mean transprosthetic gradient and paravalvular leak) or leaflet thickening at short-term follow-up. Overall, the self-expanding Evolut™ transcatheter valve demonstrated consistent valve performance in bicuspid AS: stent frame under-expansion and ellipticity at the inflow level did not affect valve haemodynamic or leaflet thickening at short-term follow-up.

Keywords: CT; bicuspid aortic valve; leaflet thickening; transcatheter aortic valve implantation; valve ellipticity; valve expansion; valve performance.

Lay summary: This study looked at how a specific self-expanding heart valve (the Evolut™) performs when implanted using a catheter (TAVI) in people with a two-leaflet aortic valve (bicuspid), which is shaped more like an oval (elliptic) than the usual round three-leaflet valve. The main finding was that the bottom part, or inflow, of the implanted metal frame (stent) didn't expand as much and was more oval-shaped compared to the top part where the new leaflets sit. However, despite this under-expansion and oval shape at the bottom, the new valve worked well overall. It did not negatively affect blood flow through the valve or cause significant leaking around it in the short term.

Using PET-CT assessment of quantitative perfusion, Fast Rb-82 infusion is more precise than slow infusion

Koos A, Milani RV, Velasco-Gonzalez C, et al.

The impact of fast vs. slow rubidium-82 infusion profile on precision and accuracy of PET myocardial blood flow perfusion metrics using a 1-tissue compartment model.

European Heart Journal - Imaging Methods and Practice, 2025; 4:qyaf132; https://doi.org/10.1093/ehjimp/qyaf132

This methodological study evaluated the impact of varying infusion rates of rubidium-82 (Rb-82) on the precision and accuracy of dynamic myocardial perfusion positron emission computed tomography (PET) imaging using a 1-tissue compartment model (1-TCM) as implemented in a commercially available software (4DM, INVIA, Ann Arbor, Michigan). Specifically, 98 subjects underwent repeated Rb-82 PET acquisitions, either at rest and after stress, with randomized fast (F, 50 mL/min) or slow (S, 20 mL/min) tracer infusions. Moreover, the accuracy of the 1-TCM was compared with the «Gould’s simplified retention model» (GSRM included in the HeartSee software, University of Texas Houston, Houston, TX), previously shown to demonstrated elevated repeatability and accuracy in similar experimental settings.

Regarding the 1-TCM, fast infusion yielded better precision, with lower repeatability coefficients and coefficient of variation for F-F vs S-S resting pairs (24.3% vs. 32.9% and 12.9% vs. 17.4%, respectively; P = 0.03). No difference in the estimation of resting myocardial blood flow (MBF) or stress MBF was revealed between infusion rates (rMBF: 0.93 vs. 0.94 mL/min/g; sMBF: 2.23 vs. 2.30 mL/min/g). When only myocardial segments with a transmural scar (TMS) were analysed (i.e., a continuous defect with ≥ 20% of the LV with relative uptake ≤50% without evidence of viability) GSRM produced consistently lower rMBF values (<0.30 mL/min/g), while 4DM 1-TCM overestimated rMBF (Fast: 0.79 ± 0.33; Slow: 0.82 ± 0.27 mL/min/g, P = 0.791), for both infusion profiles.

The Authors concluded that 1-TCM shows an elevated precision in MBF quantification when a fast Rb-82 infusion is used. However, 1-TCM overestimates rMBF in TMS regardless of infusion rate. GSRM remains accurate and precise across Rb-82 infusion profiles.

Keywords: PET perfusion; rubidium-82; myocardial blood flow; -tissue compartment model, tracer’s infusion rate.

Lay summary: PET-based quantification of absolute MBF plays a relevant role in managing coronary artery disease (CAD). Accordingly, standardization of PET MBF quantification across imaging systems remains crucial. The present study is the first to systematically compare precision between F and S infusion profiles using the most widely adopted 1-TCM implementation in 4DM software. On the one hand, it found better precision in 1-TCM utilized by 4DM with a fast infusion of Rb-82, this being equivalent to GRSM-HeartSee output. However, 1-TCM consistently overestimated rMBF in TMS regardless of infusion rate, at variance to GSRM-HeartSee that demonstrated both accuracy and precision within TMS across F and S infusion profiles.

Reverse redistribution in myocardial perfusion imaging is associated with inducible ischaemia

Xingzhou S, Wenji Y, Qifei X, et al.

Clinical impact of reverse redistribution in myocardial perfusion imaging.

J Nucl Cardiol 2025; 53:102500; https://doi.org/10.1016/j.nuclcard.2025.102500

Reverse redistribution (RR) on nuclear cardiac imaging is a phenomenon characterized by reduced radiotracer uptake in specific myocardial regions on the thallium-201 (201 TL) redistribution image or technetium-99 m (99mTc) rest images compared to the corresponding stress images. While some consider RR a technique-related “false positive” finding, other evidence suggests a possible link between this peculiar imaging pattern and coronary functional disease (i.e., spasm or microvascular dysfunction). In the present study, 29 patients with RR on single-photon emission computed tomography (SPECT) MPI were compared to patients with normal imaging findings matched for age, sex, coronary stenosis severity, and stress imaging modality. The RR group had higher percentage of positive stress ECG (39.3 % vs 0%, P < 0.001), higher usage rate of nicorandil (25.0 % versus 0%, P < 0.001), and higher angio-based microvascular resistance (AMR) (3.49 vs 3.05, P = 0.005) than the control population with normal MPI. Conversely, the quantitative flow ratio (QFR) did not differ between groups (0.88 vs 0.87, P = 0.44) similar to the normal perfusion group. Of note, nearly 50% of the ischemic ECG changes occurred during the recovery period, suggesting a potential association between coronary spasm and RR. The Authors conclude that the association between RR, clinical and imaging signs of inducible ischemia and the AMR differences likely result from the presence of coronary microvascular disease differences as a cause of the imaging phenomenon.

Keywords: SPECT; MPI; reverse redistribution; microvascular resistance, inducible ischemia.

Lay summary: RR is a relatively infrequent imaging phenomenon of MPI that, when present, is generally considered an innocent bystander of an otherwise «normal» scan. The present study, however, adds evidence on the possible association between RR and impaired myocardial perfusion, possibly because of functional alterations of wither the macrovascular (i.e., coronary spasm) or microvascular (i.e., endothelial dysfunction) coronary tree. By comparing patients with RR to a matched population with normal MPI, the present study suggests that this peculiar imaging pattern is a hallmark of underlying myocardial ischemia that would merit adequate treatment when found.

The Relationship Between Coronary Stenoses and Myocardial Flow Abnormality

Tanja Kero, Juhani Knuuti, Sarah Bär, et al.

Coronary artery stenosis, plaque burden and severity of myocardial ischemia.

European Heart Journal - Imaging Methods and Practice, 2025; qyaf139; https://doi.org/10.1093/ehjimp/qyaf139

This study of 837 symptomatic patients combined coronary computed tomography (CCTA) with 15O-water positron emission tomography (PET) to investigate whether AI-guided quantitative CCTA (AI-QCT) plaque metrics predict myocardial ischemia severity (measured as ml/g/min). AI-QCT quantified diameter stenosis and plaque burden, percent atheroma volume (PAV), non-calcified plaque volume (NCPV), and calcified plaque volume (CPV). Ischemia severity correlated with increasing stenosis and plaque burden across all major coronary arteries. The left anterior descending artery exhibited the highest atherosclerotic burden. Diameter stenosis and NCPV were significant predictors of ischemia in all vessels, while CPV predicted severity only in LAD and RCA. These findings underscore the comprehensive anatomical characterization of coronary arteries by AI-QCT analysis, which relates to ischemia severity.

Keywords: CCTA; PET perfusion; 15O-water; Coronary artery disease; AI analysis.

Lay summary: Researchers studied 837 patients with possible coronary disease. They combined two tests: a CT scan of the coronary arteries and a PET scan that measures the heart’s blood flow. The AI analysed plaques in the arteries. They found that a greater number of plaques and tighter arteries were associated with worse blood flow to the heart muscle. The left anterior descending artery (a major vessel) usually has the most plaque. Certain types of plaque, especially softer lipid plaques, were indicators of poor blood flow to the heart muscle.

Deep Learning Improves Standard SPECT Perfusion Imaging without Extra Radiation

Shanbhag AD, Miller RJH, Lemley M, et al.

General Purpose Deep Learning Attenuation Correction Improves Diagnostic Accuracy of SPECT MPI: A Multicenter Study.

JACC Cardiovasc Imaging 2025; 18:1235-1246; https://doi.org/10.1016/j.jcmg.2025.06.010

Attenuation correction (AC) improves the diagnostic accuracy of single-photon emission tomography (SPECT) perfusion imaging, but typically requires additional computed tomography (CT) imaging, adding cost and radiation. Moreover, the novel dedicated cardiac SPECT systems commonly lack the possibility for simultaneous CT correction of the obtained perfusion images. This multicenter study explored whether deep learning (DL) can generate synthetic AC images (DeepAC) as an alternative.

Researchers trained a DL model on 4,894 patients from 4 sites and externally validated it in 2 cohorts: 746 patients from a large clinical trial and 320 patients from another center. In the first external cohort, 28% had obstructive coronary artery disease (CAD). DeepAC significantly improved diagnostic performance for detecting obstructive CAD compared with non-attenuation-corrected (NC) images (AUC 0.77 vs. 0.73; p<0.001). In the second cohort, DeepAC scores closely matched conventional AC scores and outperformed standard non-corrected perfusion imaging. The authors concluded that DeepAC offers a practical way to enhance SPECT perfusion accuracy without additional equipment, imaging time, or radiation exposure, thereby expanding access to higher-quality cardiac imaging.

Keywords: SPECT; MPI; Attenuation correction; AI, Deep learning; CZT SPECT.

Lay summary: SPECT scans can be used to image blood flow in the heart. An additional computed tomography (CT) scan is usually performed to improve image quality by providing anatomic landmarks for blood flow analysis. This is called “attenuation correction (AC)”. Researchers tested whether artificial intelligence (AI) could improve SPECT images without the need for additional CT imaging. They trained a deep learning model on nearly 5,000 patients and tested it on two large groups. The AI-generated images closely matched results from real CT-based correction. This approach could make heart scans more accurate without extra radiation or equipment, helping to deliver higher-quality cardiac imaging.

124I-Evuzamitide PET/CT Detects Early ATTR Cardiac Amyloid Missed by 99mTc-PYP Scans

Smiley DA, Einstein AJ, O’Gorman KJ, et al.

Early Detection of Transthyretin Cardiac Amyloidosis Using 124I-Evuzamitide Positron Emission Tomography/Computed Tomography.

JACC Cardiovasc Imaging 2025;18:799-811; https://doi.org/10.1016/j.jcmg.2025.01.018

This prospective pilot study evaluated whether 124I-evuzamitide PET/CT can detect myocardial transthyretin amyloid in individuals with variant or wild-type ATTR, particularly when 99mTc-pyrophosphate scintigraphy is nondiagnostic. Twenty-five subjects were enrolled, including ATTRv patients, ATTRwt patients, and TTR-variant carriers. All underwent 124I-evuzamitide PET/CT following thyroid blockade. PET-based myocardial uptake was quantified using percentage injected dose, cardiac amyloid activity, and volumetric measures.

Eleven subjects with Perugini grade 0–1 99mTc-PYP scans demonstrated clear myocardial 124I-evuzamitide uptake, indicating cardiac amyloid despite negative scintigraphy findings. This included all five ATTRv patients with biopsy-proven disease and two ATTRwt patients with extracardiac biopsy–proven ATTR but negative cardiac scintigraphy. In contrast, all subjects with positive 99mTc-PYP scans also showed PET uptake, demonstrating strong concordance in established disease. PET-derived amyloid burden correlated strongly with cardiac biomarkers, septal and posterior wall thickness, LV mass, global longitudinal strain, and myocardial contraction fraction, and moderately with NT-proBNP, Columbia score, and quality-of-life scores. These results show that 124I-evuzamitide PET/CT offers enhanced sensitivity for early cardiac involvement and provides quantitative data that may support monitoring and therapy assessment.

Keywords: PET; 124I-evuzamitide; transthyretin amyloidosis; ATTR cardiomyopathy; pyrophosphate; early detection; myocardial amyloid; quantitative imaging.

Lay summary: This study tested a new PET imaging tracer called 124I-evuzamitide to see if it can detect heart amyloid earlier than traditional scans. Standard bone-tracer imaging sometimes misses early disease, especially in people who carry hereditary ATTR variants. In this study, several patients with negative standard scans showed clear amyloid deposits on PET, including cases confirmed by biopsy. The PET results also reflected how much the heart was affected, matching blood tests and ultrasound findings. These findings suggest that this new PET scan may identify cardiac amyloidosis earlier and more accurately, helping doctors diagnose the disease sooner and monitor treatment more effectively.

Left Ventricular Cavity Size Influences Transient Ischemic Dilation Ratio in Asian Females Undergoing Normal SPECT MPI

Wong CHS, Yew MS

Relationship between left ventricular cavity size and transient ischaemic dilation ratio on dipyridamole stress single-photon emission computerized tomography myocardial perfusion imaging in a female Asian population.

European Heart Journal - Imaging Methods and Practice 2025; 3:qyaf102; https://doi.org/10.1093/ehjimp/qyaf102

This retrospective study evaluated how left ventricular cavity size affects the transient ischaemic dilation ratio in 107 Asian female patients with normal dipyridamole stress SPECT myocardial perfusion imaging. Small left ventricular cavities, defined by a gated rest end-diastolic volume below the 20th percentile, demonstrated significantly higher transient ischaemic dilation ratios compared with normal-sized ventricles despite entirely normal perfusion and preserved systolic function. Resting end-diastolic volume showed a significant inverse correlation with transient ischaemic dilation ratio, and this relationship remained after adjustment for age, body mass index, ejection fraction, diabetes, and hypertension.

These findings highlight that left ventricular cavity size is an important determinant of transient ischaemic dilation in this population and that interpretation of transient ischaemic dilation must account for cardiac chamber size rather than relying on a universal threshold applicable to all patients.

Keywords: SPECT myocardial perfusion imaging; transient ischaemic dilation; left ventricular volume; dipyridamole stress.

Lay summary: This study showed that women with naturally small hearts may have slightly higher transient ischaemic dilation values on stress SPECT imaging even when their heart is completely normal. Because of this, doctors should interpret this measurement with caution, considering the patient’s heart size to avoid unnecessary concern or additional tests.