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EACVI Research News – January 2024

European Association of Cardiovascular Imaging

The articles have been selected and commented on by members of the EACVI Research and Innovation committee (Andrea Barison, Gianluca Pontone, Ana Teresa Timoteo, Danilo Neglia, Riccardo Liga, Saloua El Messaoudi, Arti Ramkisoensing, Sonia Borodzicz-Jazdzyk, Eylem Levelt) in collaboration with the EACVI HIT Committee (Giulia Elena Mandoli, Sara Moscatelli and Christina Luong).

Among patients with a history of CABG, PET-derived global MFR <2 may identify those with a high risk of subsequent cardiovascular events, especially heart failure, independent of cardiovascular risk factors and perfusion data

Al Rifai M, Ahmed AI, Saad JM, et al. 
Prognostic value of global myocardial flow reserve in patients with history of coronary artery bypass grafting. 
Eur Heart J - Cardiovasc Imaging 2023, 24:1470–1477;

Aim of the study was to assess the prognostic role of positron emission tomography (PET)-derived myocardial flow reserve (MFR) among patients with prior coronary artery bypass grafting (CABG). The study population included 836 patients with prior CABG, 66% with MFR <2. During a median follow-up time of 12 months, there were 122 adverse events (46 heart failure admissions, 28 all-cause deaths, 23 infarctions, 22 PCI/3 repeat CABG 90 days after imaging). After adjusting for clinical and myocardial perfusion imaging variables, patients with impaired MFR (i.e. <2) had a higher risk of the primary outcome [hazard ratio (HR) 2.06; 95% CI 1.23–3.44]. Results were significant for heart failure admissions (HR 2.92; 95% CI 1.11–7.67) but not for all-cause death (HR 2.01, 95% CI 0.85–4.79), or myocardial infarctions/unplanned revascularizations (HR 1.93, 95% CI 0.92–4.05).

PET; myocardial flow reserve

chronic ischaemic heart disease
CABG; prognosis

Vasodilator stress perfusion CMR has superior diagnostic accuracy for diagnosis of significant CAD than gated SPECT

Arai AE, Schulz-Menger J, Shah DJ, et al. 
Stress Perfusion Cardiac Magnetic Resonance vs SPECT Imaging for Detection of Coronary Artery Disease. 
J Am Coll Cardiol 2023; 82: 1828-1838;

GadaCAD2 was an international, multicenter, prospective, Phase 3 clinical trials that led to U.S. Food and Drug Administration approval of gadobutrol to assess myocardial perfusion and late gadolinium enhancement (LGE) in adults with known or suspected coronary artery disease (CAD). A prespecified secondary objective was to determine if vasodilator stress perfusion CMR (adenosine or regadenoson, performed with gadobutrol 0.1  mmol/kg body weight total dose) was noninferior to SPECT (physical or vasodilator stress, performed with Tc-99m sestamibi or Tc-99m tetrofosmin) for detecting significant CAD. In a final cohort of 294 patients, significant CAD was present in 72 (24.5%) patients, as defined by a ≥70% stenosis at coronary angiography or computed tomography.  Stress perfusion CMR was statistically superior to gated SPECT for specificity (P = 0.002), area under the receiver operating characteristic curve (0.88 for CMR, 0.74 for SPECT, P < 0.001), accuracy (0.85 for CMR, 0.75 for GSPECT, P = 0.003), positive predictive value (P < 0.001), and negative predictive value (P = 0.041), while sensitivity was not significantly different.

Stress perfusion CMR; SPECT; diagnostic performance

chronic ischaemic heart disease 
Obstructive CAD

In patients undergoing stress CMR, the stress-LGE analysis has superior diagnostic accuracy but similar prognostic significance than the conventional stress-rest analysis

Swoboda PP, Matthews GDK, Garg P, et al.
Comparison of Stress-Rest and Stress-LGE Analysis Strategy in Patients Undergoing Stress Perfusion Cardiovascular Magnetic Resonance.
Circ Cardiovasc Imaging 2023; 16:e014765;

In this analysis of CE-MARC, the optimal method of analysis of stress CMR images was investigated, considering both the diagnostic accuracy compared with angiographic data and the long term prognosis. In 666 patients with complete stress perfusion, rest perfusion, late gadolinium enhancement (LGE), and quantitative coronary angiography data, the stress-LGE analysis (whereby a segment is defined as ischemic if it has a subendocardial perfusion defect with no infarction) was compared with the stress-rest method validated in the original CE-MARC analysis. The diagnostic accuracy of the stress-LGE method was evaluated with different thresholds of infarct transmurality used to define whether an infarcted segment had peri-infarct ischemia. The optimal stress-LGE analysis classified all segments with a stress perfusion defect as ischemic unless they had >75% infarct transmurality (area under the curve, 0.843; sensitivity, 75.6%; specificity, 93.1%; P<0.001). This analysis method has superior diagnostic accuracy to the stress-rest method (area under the curve, 0.834; sensitivity, 73.6%; specificity, 93.1%; P<0.001, P value for difference=0.02). Patients were followed-up for median 6.5 years for major adverse cardiovascular events, with the presence of inducible ischemia by either the stress-LGE or stress-rest analysis being similar and strongly predictive (hazard ratio, 2.65; P<0.001, for both).

stress perfusion; rest perfusion; LGE; diagnostic accuracy    

chronic ischaemic heart disease 
CAD; stress imaging

Left ventricular global longitudinal strain is a prognostic parameter in hypertrophic cardiomyopathy 

Choi YJ, Lee HJ, Park JS, et al. 
Left ventricular global longitudinal strain as a prognosticator in hypertrophic cardiomyopathy with a low-normal left ventricular ejection fraction. 
Eur Heart J Cardiovasc Imaging 2023; 24:1374-1383;

This study investigated the prognostic value of left ventricular global longitudinal strain (LV-GLS) in 349 patients with hypertrophic cardiomyopathy (HCM) and a left ventricular ejection fraction (LVEF) of 50–60%. The primary focus was on the occurrence of cardiovascular death, including sudden cardiac death (SCD) and SCD-equivalent events, over a median follow-up of 4.1 years. Secondary outcomes included SCD/SCD-equivalent events, cardiovascular death, and all-cause death.
Key findings revealed that LV-GLS was independently associated with the primary outcome, even after adjusting for age, atrial fibrillation, ischaemic stroke, LVEF, and left atrial volume index. A significant cut-off value of 10.5% for LV-GLS was identified, with patients having LV-GLS ≤ 10.5% facing a higher risk of the primary outcome. This value also independently predicted each secondary outcome.
In conclusion, the study demonstrated that LV-GLS is a significant independent predictor of cardiovascular death, including SCD/SCD-equivalent events, in HCM patients with an LVEF of 50–60%. This suggests that measuring LV-GLS can be crucial for risk stratification in these patients, potentially guiding clinical decision-making and improving patient management.



Mitral regurgitation, left ventricle global longitudinal strain and right ventricular-arterial coupling predict 1-year mortality in patients with aortic stenosis undergoing transcatheter aortic valve replacement

Gutierrez-Ortiz E, Olmos C, Carrión-Sanchez I, et al. 
Redefining cardiac damage staging in aortic stenosis: the value of GLS and RVAc.
Eur Heart J Cardiovasc Imaging 2023; 24:1608-1617;

The study aimed to stratify patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR), in order to develop a novel staging model and compare its predictive performance with previously published cardiac damage staging systems. The study included 496 patients (mean age 82.1 ± 5.9 years, 53% female) undergoing TAVR from 2017 to 2021 from a single-centre prospective registry. Mitral regurgitation (MR), left ventricle global longitudinal strain (LV-GLS) and right ventricular-arterial coupling (RVAc) at pre-procedural echocardiography were independent predictors of all-cause 1-year mortality. A new classification system with four different stages was developed using LV-GLS, MR, and RVAc. The area under the receiver operating characteristic curve was 0.66 (95% confidence interval 0.63-0.76), and its predictive performance was superior compared with the previously published systems (P < 0.001).
Cardiac damage staging might have an important role in patients' selection and better timing for TAVR. A model that includes LV-GLS, MR, and RVAc may help to improve prognostic stratification and contribute to better selection of patients undergoing TAVR.


valvular heart disease 
aortic stenosis

An impaired right ventricular longitudinal strain predicts an adverse prognosis in patients with secondary mitral regurgitation undergoing transcatheter edge-to-edge mitral valve repair

Lupi L, Italia L, Pagnesi M, et al. 
Prognostic value of right ventricular longitudinal strain in patients with secondary mitral regurgitation undergoing transcatheter  edge-to-edge mitral valve repair. 
Eur Heart J Cardiovasc Imaging 2023; 24:1509-1517;

Secondary mitral regurgitation (SMR) is common in patients with heart failure and reduced left ventricular ejection fraction and is associated with poor outcomes. Transcatheter edge-to-edge repair (TEER) is a valid treatment option for selected symptomatic patients with relevant SMR. Several echocardiographic parameters have been associated with poor prognosis in this setting of patients. The prognostic significance of right ventricular dysfunction (RVD) in SMR was evaluated in several studies but the role of RV longitudinal strain (RVLS) has not been evaluated, while it can detect subclinical RVD and better predict patient outcome in conditions of pressure or volume overload. This retrospective study investigated the prognostic value of pre-procedural RVLS in 142 patients with SMR undergoing TEER in comparison with other conventional echocardiographic parameters of RV systolic function. At 1-year follow-up 45 patients reached the composite endpoint of all-cause death or heart failure hospitalization. The best cut-off value of RV free-wall longitudinal strain (RVFWLS) to predict outcome was -18% [sensitivity 72%, specificity of 71%, area under curve (AUC) 0.78, P < 0.001], whereas the best cut-off value of RV global longitudinal strain (RVGLS) was -15% (sensitivity 56%, specificity 76%, AUC 0.69, P < 0.001). Prognostic performance was suboptimal for tricuspid annular plane systolic excursion, tricuspid lateral annular systolic velocity at tissue Doppler imaging and fractional area change (FAC). 
This study showed that RVLS is a useful and reliable tool to identify patients with SMR undergoing TEER at high risk of mortality and HF hospitalization, on top of other clinical and echocardiographic parameters, with RVFWLS offering the best prognostic performance.


valvular heart disease 
Echo, mitral valve regurgitation, TEER, prognostic indicators

The anatomical variability of the transverse sinus affects cardiac erosion after atrial septal closure device implantation

V Muroke, S Tuohinen, M Jalanko et al.    
Anatomical variability of transverse sinus and its implication on atrial septal defect closure device erosion.
Eur Heart J Cardiovasc Imaging 2023; 24:1563-1565;

The transverse sinus (TS) is a tunnel-shaped passage in the pericardial cavity, posterior to the aorta and pulmonary trunk, and anterior to the superior vena cava and pulmonary veins. In atrial septal defect (ASD) closure, the device sits close to the TS. Thus, anatomical variability of the TS could be a risk factor for cardiac erosion. This study aims to evaluate the anatomical variability of the TS and define anatomical characteristics associated with ASD closure device erosion. Transoesophageal echocardiography and computed tomography were used to measure the distance to the TS during systole from the hinge point of the aortic valve (AV) in long-axis images (LAX). In this study, the Authors showed significant variability in the anatomy of the TS. CT and TEE–measured distance to TS correlated well in short-axis and long-axis measurements. Patients with ASD device cardiac erosion had a shorter distance from the atrial septum to the TS at the short-axis view. This shorter distance could be a possible risk factor for cardiac erosion. However, the Authors recommend a more extensive study with more erosion cases to verify the results of this study.

TOE, transverse sinus 

congenital heart disease    
atrial septal defect, closure device, cardiac erosion

A machine learning-based score for echocardiographic assessment of hypertension-related cardiac remodeling

Alsharqi M, Lapidaire W, Iturria-Medina Y, et al. 
A machine learning-based score for precise echocardiographic assessment of cardiac remodeling in hypertensive young adults.
Eur Heart J Imaging Methods Pract 2023; 1:qyad029;

Early identification of hypertension-related cardiac abnormalities before full development of left ventricular hypertrophy is very important to guide prevention strategies. The Authors developed and tested a novel semi-supervised machine learning approach for a clinically meaningful summary score of cardiac remodeling in hypertension. They used a contrastive trajectories inference approach, applied to data collected from three UK studies of young adults. Low-dimensional variance was identified in 66 echocardiography variables from participants with hypertension (systolic ≥160 mmHg) relative to a normotensive group (systolic < 120 mmHg). A normalized score was obtained for each individual reflecting extent of cardiac remodeling between zero (health) and one (disease). A total of 411 young adults were included in the analysis, and 21 variables characterized >80% of data variance. Repeated scores for an individual in cross-validation were stable with good differentiation of normotensive and hypertensive individuals (area under the receiver operating characteristics 0.98). The derived score followed expected hypertension-related patterns in individual cardiac parameters at baseline and reduced after exercise, proportional to intervention compliance and improvement in ventilatory threshold. This quantitative score generated from a computational model summarizes hypertension-related cardiac remodeling in young and it might allow more personalized early prevention advice, but further evaluation of clinical applicability is still required.

Artificial intelligence

hypertensive heart disease    

Left ventricular global work index is independently associated with all-cause mortality in patients undergoing TAVR

Wu HW, Fortuni F, Butcher SC, et al.
Prognostic value of left ventricular myocardial work indices in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement.
Eur Heart J Cardiovasc Imaging 2023; 24:1682-1689;

The Authors evaluated the prognostic value of LV myocardial work indices in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. LV global work index (LV GWI), LV global constructive work (LV GCW), LV global wasted work (LV GWW), and LV global work efficiency (LV GWE) were calculated in 281 patients before the procedure. During a median follow-up of 52 months, 64 patients died. LV GWI was the only LVMW parameter independently associated with all-cause mortality (Hazard ratio per-tertile-increase 0.639; 95%CI 0.463–0.883; P = 0.007. Furthermore, when added to a basal model, LV GWI yielded a higher increase in predictivity compared to the left ventricular ejection fraction as well as LV global longitudinal strain and LV GCW, and also across the different hemodynamic categories (including low-flow low-gradient) of AS. Therefore, LV GWI is independently associated with all-cause mortality in patients undergoing TAVR and has a higher prognostic value compared to both conventional and advanced parameters of LV systolic function.

Echocardiography; Myocardial Work    

valvular heart disease     
Aortic stenosis

The right ventricle-to-pulmonary artery coupling predicts the risk of mortality or HF hospitalization in cardiac amyloidosis patients

Tomasoni D, Adamo M, Porcari A, et al.    
Right ventricular to pulmonary artery coupling and outcome in patients with cardiac amyloidosis.
Eur Heart J Cardiovasc Imaging 2023; 24:1405-1414;

Right ventricle-to-pulmonary artery (RV-PA) coupling was evaluated by using the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio in 283 patients with either transthyretin (ATTR) or immunoglobulin light-chain (AL) cardiac amyloidosis (CA). The median value of TAPSE/PASP was 0.45 (0.33–0.63) mm/mmHg. Patients with a TAPSE/PASP ratio <0.45 were older, had lower systolic blood pressure, more severe symptoms, higher cardiac troponin and N-terminal pro-B-type natriuretic peptide levels, greater left ventricular (LV) thickness, and worse LV systolic and diastolic function. A TAPSE/PASP ratio <0.45 was independently associated with a higher risk of all-cause death or heart failure (HF) hospitalization [hazard ratio (HR) 1.98] and all-cause death (HR 2.18). The TAPSE/PASP ratio reclassified the risk of both endpoints, while TAPSE or PASP alone did not. The prognostic impact of the TAPSE/PASP ratio was significant both in AL-CA patients and in ATTR-CA. The receiver operating characteristic curve showed that the optimal cut-off for predicting prognosis was 0.47 mm/mmHg. Therefore, in patients with cardiac amyloidosis, RV-PA coupling predicted the risk of mortality or HF hospitalization.

right ventricular coupling, pulmonary artery coupling

cardiac amyloidosis

Right ventricular forward stroke volume/ESV at 3D-echocardiography is a strong predictor of death and heart failure hospitalization in patients with secondary tricuspid regurgitation

Gavazzoni M, Badano LP, Cascella A, et al    
Clinical Value of a Novel Three-Dimensional Echocardiography–Derived Index of Right Ventricle–Pulmonary Artery Coupling in Tricuspid Regurgitation
J Am Soc Echocardiogr 2023; 36:1154-1166.e3;

One hundred eight patients with moderate or severe secondary tricuspid regurgitation were included in this study. To overcome the difficulties associated with pulmonary artery systolic pressure estimation in patients with significant tricuspid regurgitation, right ventricle–to–pulmonary artery (RV-PA) coupling was assessed by a surrogate obtained by 3D Echocardiography as RV forward stroke volume / RV end-systolic volume. At a median follow-up of 24 months, 72 patients (40%) had reached the composite end point of death of any cause and heart failure hospitalization. RV forward SV/ESV was significantly more related to the composite end point than RV ejection fraction and a value of 0.40 was found to best correlate with outcome. On multivariate Cox regression, RV forward SV/ESV, tricuspid annular plane systolic excursion/PASP, and RV free wall longitudinal strain/PASP were all independently associated with the occurrence of the composite end point when added to a group of parameters including STR severity (severe vs moderate), atrial fibrillation, pulmonary arterial hypertension, right atrial volume, RV end-diastolic volume, and RV free wall longitudinal strain. RV forward SV/ESV < 0.40 (HR, 3.36) carried higher related risk than RV free wall longitudinal strain/PASP < −0.42%/mm Hg (HR, 3.1) and tricuspid annular plane systolic excursion/PASP < 0.36 mm/mm Hg (HR, 2.69). RV ejection fraction did not correlate independently with prognosis when added to the same group of variables. Therefore, this parameter can be used to predict the risk for death and heart failure hospitalization in patients with secondary tricuspid regurgitation.

3D Echocardiography, right verntricular coupling, pulmonary artery Coupling    

valvular heart disease 
Tricuspid regurgitation

Echocardiographic reference values from a large Norwegian population

Eriksen-Volnes T, Grue JF, Hellum Olaisen S, et al    
Normalized Echocardiographic Values From Guideline-Directed Dedicated Views for Cardiac Dimensions and Left Ventricular Function
JACC Cardiovasc Imaging 2023; 16:1501-1515;

This is a prospective study on 2,462 healthy individuals that participated in the fourth wave of the HUNT (Trøndelag Health) study in Norway and underwent a comprehensive echocardiographic study. From this large cohort, 1,412 were classified as normal and the Authors derived an updated normal reference ranges for dimensions and volumes of all cardiac chambers as well as central Doppler measurements, according to sex and age, obtained with 2- and 3-dimensional echocardiography. Volumetric measures were indexed to body surface area and height in powers of 1 to 3. Left ventricular ejection fraction had lower normal limits of 50.8% for women and 49.6% for men. According to sex-specific age groups, the upper normal limits for left atrial end-systolic volume indexed to body surface area ranged from 44 mL/m2 to 53 mL/m2, and the corresponding upper normal limit for right ventricular basal dimension ranged from 43 mm to 53 mm. Indexing to height raised to the power of 3 accounted for more of the variation between sexes than indexing to body surface area. The higher upper normal limits for left atrial volume and right ventricular dimension highlight the importance of updating reference ranges accordingly following refinement of echocardiographic methods.

Reference values

normal/healthy people    
healthy individuals

An impaired LA strain identifies cardiac amyloid patients with high thrombotic risk, independent of atrial fibrillation

Akintoye E, Majid M, Klein AL, et al.    
Prognostic Utility of Left Atrial Strain to Predict Thrombotic Events and Mortality in Amyloid Cardiomyopathy
JACC Cardiovasc Imaging 2023; 16:1371-1383;

The Authors identified patients with light chain (AL) or transthyretin (ATTR) cardiac amyloidosis and no history of atrial fibrillation (AF) at diagnosis. Left atrial strain was evaluated as a predictor of incident thrombotic events (TE). In addition, the Authors evaluated the incremental utility of adding LA strain to current prognostic staging systems. They included 448 patients (50.2% AL; 49.8% ATTR) with median follow-up of 3.8 years. There were 64 (14.3%) thrombotic cases, 103 (23%) AF cases, and 234 (52.2%) deaths. Notably, 75% of TEs occurred without preceding AF documented. LA reservoir strain and LA contractile strain predicted TE (HR 2.22 and 2.63 per SD decrease, respectively), AFa and mortality (HR 1.32 and 1.49 per SD decrease, respectively). Moreover, LA reservoir strain and LA contractile strain significantly improved the C-statistics of the Mayo AL staging from 0.65 to 0.68 and 0.70, respectively; Mayo ATTR staging (0.73 to 0.79 and 0.80, respectively); and Gillmore ATTR staging (0.70 to 0.79 and 0.80, respectively). Therefore, LA strain identifies cardiac amyloid patients with high thrombotic risk (independent of AF) and improves current prognostic staging.


thrombosis, thrombotic events, mortality

In patients with arrhythmogenic right ventricular cardiomyopathy, RV longitudinal strain adds diagnostic value, while LV longitudinal strain adds prognostic values for identification of high-risk patients

Namasivayam M, Bertrand PB, Bernard S, et al.
Utility of Left and Right Ventricular Strain in Arrhythmogenic Right Ventricular Cardiomyopathy: A Prospective Multicenter Registry
Circ Cardiovasc Imaging 2023; 16:e015671;

Patients with suspected arrhythmogenic right ventricular cardiomyopathy (ARVC) (n = 109) from a prospective multicenter registry (North American ARVC Registry) were clinically phenotyped using the 2010 ARVC Revised Task Force Criteria and underwent baseline strain echocardiography. Estimation of RV strain was feasible in 99/109 (91%), and LV strain was feasible in 78% patients. RV global longitudinal strain and RV free wall strain had diagnostic area under the receiver operating characteristic curve of 0.76 and 0.77, respectively (both P<0.001; difference NS). Abnormal RV global longitudinal strain phenotype (RV global longitudinal strain > −17.9%) and RV free wall strain phenotype (RV free wall strain > −21.2%) were identified in 59% and 81% of subjects, respectively, who were not identified by conventional echocardiographic criteria but still met the overall 2010 ARVC Revised Task Force Criteria for ARVC. LV global longitudinal strain did not add diagnostic value but was prognostic for composite end points of death, heart transplantation, or ventricular arrhythmia (log-rank P=0.04). Therefore, RV strain assessment added diagnostic value to current echocardiographic criteria by identifying patients who are missed by current echocardiographic criteria yet still fulfill the diagnosis of ARVC. 

left ventricular strain, right ventricular strain

arrhythmogenic right ventricular cardiomyopathy

A novel deep learning model can identify severe aortic stenosis from a single parasternal long axis video at transthoracic echocardiography without Doppler imaging     

Holste G, Oikonomou EK, Mortazavi BJ, et al.    
Severe aortic stenosis detection by deep learning applied to echocardiography
Eur Heart J 2023; 44: 4592-4604;

In this study a deep learning model was developed in a training set of 5257 studies to detect severe AS using single-view 2D echocardiography. The model was validated in a temporally distinct set of 2040 consecutive studies achieving an AUC of 0.978 (95% CI: 0.966, 0.988) for detecting severe AS, as well as in two geographically distinct cohorts of 4226 and 3072 studies, yielding an AUC of 0.952 (95% CI: 0.941, 0.963) and 0.942 (95% CI: 0.909, 0.966), respectively. The model was interpretable with saliency maps identifying the aortic valve, mitral annulus, and left atrium as the predictive regions. Among non-severe AS cases, predicted probabilities were associated with worse quantitative metrics of AS suggesting an association with various stages of AS severity. These results underline the potentialities of an automated approach for using single-view 2D echocardiography and its possible utility for point-of-care screening.

Echocardiography, Artificial Intelligence    

valvular heart disease
Aortic Stenosis


Lipoprotein(a) is tightly associated with larger volumes of calcification in the coronary arteries, aortic arch, extracranial carotid arteries, and intracranial carotid arteries

Singh SS, van der Toorn JE, Sijbrands EJG, et al.
Lipoprotein(a) is associated with a larger systemic burden of arterial calcification.
Eur Heart J Cardiovasc Imaging 2023; 24:1102-1109;

In this large population-based study, 2354 participants underwent non-contrast CT to assess arterial calcification burden in multiple districts, as a hallmark of arteriosclerosis, and its association with plasma Lp(a) levels. In particular, the volume of coronary artery calcification (CAC), aortic arch calcification (AAC), extracranial (ECAC), and intracranial carotid artery calcification (ICAC) was calculated.   It was consistently demonstrated that higher Lp(a) was associated with a larger calcification burden in all major arteries.  In the highest Lp(a) percentile, severe ICAC was most prevalent in women [fully adjusted odds ratio (OR) 2.41, 95% CI 1.25-4.63], while severe AAC in men (fully adjusted OR 3.29, 95% CI 1.67-6.49). The findings of this study underline the emerging role of Lp(a) as a systemic risk factor for arteriosclerosis and Lp(a)-reducing therapies may reduce the burden from arteriosclerotic events throughout the arterial system.

Non Contrast CT, Arterial Calcifications    

vascular diseases    
Systemic atherosclerosis


Statin treatment reduces plaque progression, particularly in lesions with a higher number of high risk features

Park HB, Arsanjani R, Sung JM, et al.    
Impact of statins based on high-risk plaque features on coronary plaque progression in mild stenosis lesions: results from the PARADIGM study
Eur Heart J Cardiovasc Imaging 2023; 24:1536-1543;

In this subanalysis from the PARADIGM registry the Authors investigated the impact of statins on coronary plaque progression according to high-risk coronary atherosclerotic plaque (HRP) features using serial CCTA exams. Overall, 1432 mild stenotic (25-49%) lesions from 613 patients who underwent serial CCTA a median inter-scan period of 3.5 ± 1.4 years were analyzed. The major finding was that in mild stenotic lesions with ≥2 HRP features, statin therapy showed a 37% reduction in annual total plaque burden (as expressed by total plaque atheroma volume) with decreased necrotic core volume and increased dense calcium volume compared to non-statin recipient mild lesions. The key factors for rapid plaque progression were ≥2 HRPs, current smoking and diabetes. The results of this study underline the relevance of characterizing by CCTA the presence of HRP features in patients with mild coronary lesions, as a strong predictor of rapid plaque progression possibly indicating aggressive statin therapy.

CT Angiography, High Risk Plaque Features    

chronic ischaemic heart disease 
Coronary Atherosclerosis


Coronary computed tomography angiography reduces the need to invasive coronary angiography inpatients with stable chest pain 

Machado MF, Felix N, Melo PHC, et al. 
Coronary Computed Tomography Angiography Versus Invasive Coronary Angiography in Stable Chest Pain: A Meta-Analysis of Randomized Controlled Trials
Circ Cardiovasc Imaging 2023; 16:e015800;

This is a meta-analysis of large trials comparing coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA) among patients with stable chest pain, who were initially referred to ICA. Five randomized controlled trials with a total of 5727 patients were included. In the follow-up ranging from 1 to 3.5 years, patients randomized to CCTA first underwent ICA only in 23% of cases and had lower rates of coronary revascularization and stroke as compared with patients randomized to ICA first. Cardiovascular mortality, major adverse cardiovascular events (MACEs), nonfatal myocardial infarction and cardiovascular hospitalizations did not differ significantly between the two groups. The results of this meta-analysis reinforce the recent multiple evidence that in patients with stable chest pain CCTA may avoid the need for ICA (even in those directly referred to the invasive study) in almost 3 out of 4 patients with a reduction in the rates of coronary revascularization and stroke without any detrimental effect on cardiovascular mortality and other MACEs.

CT Angiography    

chronic ischaemic heart disease 
Coronary Artery Disease


Cardiac magnetic resonance is a valid alternative to computed tomography for guiding transcatheter aortic valve replacement

Reindl M, Lechner I, Holzknecht M, et al.
Cardiac Magnetic Resonance Imaging Versus Computed Tomography to Guide Transcatheter Aortic Valve Replacement: A Randomized, Open-Label, Noninferiority Trial
Circulation 2023; 148:1220-1230;

Computed tomography (CT) is recommended for guiding transcatheter aortic valve replacement (TAVR). However, a sizable proportion of TAVR candidates have chronic kidney disease, in whom the use of iodinated contrast media is a limitation. Cardiac magnetic resonance imaging (CMR) is a promising alternative, but randomized data comparing the effectiveness of CMR-guided versus CT-guided TAVR are lacking. A prospective, randomized, open-label, noninferiority trial was conducted to evaluate the usefulness of CMR in TAVR planning. Overall, 380 candidates to TAVR were randomized (1:1) to CMR-guided (191 patients) or CT-guided (189 patients) TAVR planning. The primary outcome was defined according to the Valve Academic Research Consortium-2 definition of implantation success at discharge, including absence of procedural mortality, correct positioning of a single prosthetic valve, and proper prosthetic valve performance. CMR-guided TAVR was noninferior to CT-guided TAVR in terms of device implantation success (93.5% in the CMR group vs. 90.7% in the CT group; p<0.01 for noninferiority). CMR can therefore be considered as an alternative for TAVR planning.

CMR, CT angiography    

valvular heart disease 
Aortic stenosis, TAVR, TAVI


In patients with previous coronary artery bypass, coronary computed tomography angiography before invasive coronary angiography reduces procedure time and contrast-induced nephropathy, with improved patient satisfaction

Jones DA, Beirne AM, Kelham M, et al    
Computed Tomography Cardiac Angiography Before Invasive Coronary Angiography in Patients With Previous Bypass Surgery: The BYPASS-CTCA Trial
Circulation 2023; 148:1371-1380;

Patients with previous coronary artery bypass grafting (CABG) often require invasive coronary angiography (ICA). However, for these patients, the procedure is technically more challenging and has a higher risk of complications. This study was a single-center, open-label randomized controlled trial assessing the benefit of adjunctive CTCA in patients with previous coronary artery bypass grafting referred for ICA. Patients were randomized 1:1 to undergo CTCA before ICA or ICA alone. Over 3 years, 688 patients were randomized with a median follow-up of 1.0 years. The mean age was 69.8±10.4 years; the median time from coronary artery bypass grafting to angiography was 12.0 years, and there were a median of 3 (interquartile range, 2 to 3) grafts per participant. Procedure duration of the ICA was significantly shorter in the CTCA+ICA group, alongside improved mean ICA satisfaction scores and reduced incidence of contrast-induced nephropathy. Procedural complications and 1-year major adverse cardiac events were also lower in the CTCA+ICA group. For patients with previous coronary artery bypass grafting, CTCA before ICA leads to reductions in procedure time and contrast-induced nephropathy, with improved patient satisfaction. 

CT angiography    

chronic ischaemic heart disease 
Coronary atherosclerosis, pre-operative evaluation


Multimodality imaging is important for the management of patients with cancer-related marantic endocarditis

F Deharo, Arregle F, Bohbot Y et al.
Multimodality imaging in marantic endocarditis associated with cancer: a multicentric cohort study
Eur Heart J Cardiovasc Imaging 2023; 24:1620-1626;

In this retrospective multicentric study, the Authors investigated the role of multimodality imaging in the diagnosis of marantic endocarditis (ME) associated with cancers and described the clinical characteristics, management, and outcome of these patients. A total of 47 patients with a diagnosis of ME were included. Vegetations were detected by echocardiography in all cases and in 12 cases (26%) by computed tomography (CT). The most common cardiac valve involved was aortic (34 cases, 73%). Twenty-two patients (46%) had a known cancer before ME, and 25 cases (54%) were diagnosed thanks to multimodality imaging. 18F-fluorodeoxyglucose positron emission tomography (18FDG PET) was performed in 30 patients (64%) and allowed a new diagnosis of cancer in 14 patients (30%). No patient had an increased 18F-FDG cardiac valve uptake. Systemic embolism was frequent (40 patients, 85% of cases). Forty-one patients (87%) were treated medically with anticoagulation therapy. One-year mortality was 55% (26 patients). Multimodality imaging is of utmost importance for the diagnosis and management of ME, which remains associated with a high risk of complications and death.

Echocardiography, Computed Tomography, 18F-FDG PET/CT    

Marantic Endocarditis


A novel prediction model for the clinical diagnosis of TTR cardiac amyloidosis

Arana-Achaga X, Goena-Vives C, Villanueva-Benito I, et al.
Development and Validation of a Prediction Model and Score for Transthyretin Cardiac Amyloidosis Diagnosis: T-Amylo    
JACC Cardiovasc Imaging 2023; 16: 1567-1580;

The diagnosis of transthyretin (TTR) cardiac amyloidosis frequently requires a multimodality imaging assessment and the integration of numerous clinical and imaging "red flags". yet, in a sizable proportion of patients the final diagnosis remains inconclusive after non-invasive imaging evaluation (i.e. in the presence of low-grade cardiac uptake at bone scintigraphy). On the other hand, the access to high-end non-invasive imaging tests (i.e. scintigraphy and cardiac magnetic resonance) is largely limited in low-to-middle income countries, posing the risk of missed diagnoses. In this context, a prediction model based on easily accessible clinical and imaging variables is eagerly awaited. In this article, a prediction model for the detection of TTR cardiac amyloidosis was created in a derivation sample of 227 patients from 2 centers (108 of whom had ascertained disease) using multivariable logistic regression with clinical, electrocardiography, analytical, and transthoracic echocardiography variables. A simplified score was also created. Both of them were validated in an external cohort (n = 895) from 11 centers. The obtained prediction model combined age, gender, carpal tunnel syndrome, interventricular septum in diastole thickness, and low QRS interval voltages, showing an area under the curve of 0.92. The T-Amylo prediction model showed a good performance in the validation sample (AUC 0.84), while the T-Amylo score showed an AUC of 0.82, including patients with hypertensive cardiomyopathy, severe aortic stenosis, and heart failure with preserved ejection fraction. Nevertheless, while in patients with either low and high score the diagnosis could be either refuted or confirmed, respectively, a considerable proportion of patients (40% for the T-Amylo model and 59% for the T-Amylo score) had still inconclusive results, needing further assessment.    

Bone scintigraphy; ultrasound    

Infiltrative cardiomyopathy; clinical prediction model    



Multimodality imaging assessment of the impact of contemporary chest irradiation protocols in breast-cancer patients    

Krug P, Geets X, Berlière M, et al.    
Cardiac structure, function and coronary anatomy 10 years after isolated contemporary adjuvant radiotherapy in breast cancer patients with low cardiovascular baseline risk
Eur Heart J Cardiovasc Imaging 2023:jead338;

Data on the effect of chest radiotherapy (RT) in patients with breast cancer (BC) are quite outdated and the possible impact of contemporary (low-dose) irradiation protocols on long-term cardiac structural and functional parameters is still a matter of discussion. For this reason, the Authors aimed at evaluating the long-term (>11 years) effects of isolated contemporary low-dose BC RT on the heart in a population of 76 BC survivors (originally treated with only RT +/- hormonal therapy) compared to 54 controls. The study population was submitted to a multimodality imaging protocol comprising 2D-echocardiography, CTCA, CMR, 6MWT and laboratory analysis to detect structural and/or functional signs of cardiac damage. Aside from minor alterations of regional strains and diastolic parameters, women who received isolated RT for BC had low prevalence of coronary disease, normal global systolic function, NT pro BNP and exercise capacity and showed no structural changes by CMR (beside a limited divergence in native T1 values), refuting significant long-term cardiotoxicity in such low-risk patients. Although present data are quite reassuring, larger prospective investigations will be needed to better address the possible cardiovascular impact of RT.

CT; CMR; 6MWT    



Prevalence and prognostic impact of dyspnea in patients with suspected chronic coronary syndromes

Rozanski A, Gransar H, Sakul S, et al.    
Increasing frequency of dyspnea among patients referred for cardiac stress testing
J Nucl Cardiol 2023; 30:2303-2313;

The clinical characteristics of patients with chronic coronary syndromes (CCS) referred to non-invasive stress myocardial perfusion imaging (MPI) has radically changed in the recent decades, with a consistent relative decrease of those presenting typical anginal chest pain and a radical decrease of the overall positivity rate of MPI, as repeatedly confirmed by appraisals reporting data on both SPECT and PET imaging. Quite recently, the clinical value of dyspnea has been underlined also in patients with CCS, as also supported by the recent ESC guidelines that consider this symptom as a ischemia-equivalent. However, the actual prevalence of dyspnea in contemporary patients with CCS referred to stres MPI is yet unknown, as is also is possibly prognostic impact. To this purpose, the Authors aimed at assessing the frequency, change in prevalence, and prognostic significance of dyspnea in a population of 33,564 patients undergoing stress/rest SPECT-MPI between 2002 and 2017. The data showed that there was a stepwise increase in the temporal prevalence of dyspnea in the last 2 decades, going from 25% to almost 40% of patients. The adjusted hazard ratio for mortality was higher among patients with dyspnea vs those without dyspnea both among all patients, and within each chest pain subgroup. In conclusion, dyspnea has become increasingly prevalent among patients referred for cardiac stress testing and is now present among nearly two-fifths of contemporary cohorts referred for stress MPI, bearing a relevant adverse prognostic impact.

Nuclear cardiac imaging; stress test    

chronic ischaemic heart disease 
chronic coronary syndrome; stable angina


Correlation between pericoronary adipose tissue attenuation, coronary plaque burden and risk features in chronic coronary syndromes    

Giesen A, Mouselimis D, Weichsel L, et al.    
Pericoronary adipose tissue attenuation is associated with non-calcified plaque burden in patients with chronic coronary syndromes    
J Cardiovasc Comput Tomogr 2023; 17:384-392;

The pathophysiology of the progression of coronary plaque burden is still a matter of intense investigation, with much attention recently devoted to the paracrine role of mediators secreted by the pericoronary adipose tissue, whose effect in modulating inflammatory signals has been recently reported. Pericoronary adipose tissue attenuation (PCAT) is an innovative marker of inflammation of the pericoronary fat tissue that can be readily quantified with computed tomography coronary angiography (CTCA). While the prognostic value of PCAT has been already suggested, its relationship with underlying coronary plaque burden needs to be fully elucidated. The Authors assessed the relationship between PCAT and coronary plaque burden in 868 patients with chronic coronary syndromes (CCS). PCAT was measured in the proximal 4 cm of each of the right coronary artery (RCA), left anterior descending artery (LAD), and the left circumflex artery (LCX) and the total, calcified, and non-calcified coronary plaque burden was quantitatively measured. While weak correlations were found between PCAT and both the total plaque burden, and stenosis severity, a significant association was observed between the PCAT and non-calcified plaque burden. In addition, higher PCAT correlated with increasing number of plaques showing high-risk features. In conclusion, PCAT correlates with non-calcified plaque burden and plaques with high-risk features in patients with CCS, possibly identifying high-risk patients who could benefit from more aggressive preventive therapy.

CCTA; plaque characterization

chronic ischaemic heart disease 
Pericoronary fat; coronary plaque burden; atherosclerosis

Notes to editor

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.