Halvorsrød MI, Mohajery M, Espeland T, et al.

Mechanical Wave Velocities in Acute Myocardial Infarction: An Exploratory Study Using Three-Dimensional High Frame Rate Echocardiography.

European Heart Journal - Imaging Methods and Practice 2025; qyaf060; https://doi.org/10.1093/ehjimp/qyaf060

This exploratory study aimed to evaluate three-dimensional (3D) high frame rate (HFR) echocardiography for estimating mechanical waves in 20 patients with myocardial infarction within 48 hours of reperfusion and 20 healthy controls. Previous studies demonstrated that propagation velocity of mechanical wave obtained by 2D HFR is a non-invasive surrogate for myocardial stiffness. In this study, the authors developed a new method that combined 3D HFR acquisition with an advanced filter to create a 3D map of myocardial mechanical wave velocity. The study demonstrated that the velocity of mechanical waves was successfully measured in 85% patients with ST-elevation myocardial infarction and in all healthy controls. Results indicated that global mechanical wave velocities were higher in patients with myocardial infarction than controls (2.1±0.6m/s vs. 1.5±0.2m/s, p<0.001). On the regional level, mechanical wave velocities were higher in the infarct-related territory and segments with wall motion abnormalities compared to the corresponding territories in healthy controls. The study concluded that the novel 3D HFR echocardiography for assessing mechanical wave velocity is a highly feasibly method and enables to detect the differences between infarcted and healthy myocardium. It seems that 3D HFR echocardiography has a promising potential for non-invasive assessment of myocardial stiffness.

Keywords: echocardiography; high frame rate; 3D echocardiography; myocardial infarction; mechanical wave; myocardial stiffness

Lay summary: This study presented a new method, which is based on 3D high-frame echocardiography for assessing mechanical wave velocity, which is a measure of myocardial stiffness. The new method showed that patients with myocardial infarction had stiffer myocardium than healthy control, and it also detected the location of the myocardial infarction in the heart. This new method is very promising, and it may be used to detect cardiac diseases in a near future.

Chan NI, Atherton JJ, Krishnan A, et al.

Diastolic Dysfunction and Survival in Patients With Preserved or Mildly Reduced Left Ventricular Ejection Fraction Following Myocardial Infarction.

J Am Soc Echocardiogr 2025; 38:380-391; https://doi.org/10.1016/j.echo.2025.01.007

This study aimed to validate the prognostic utility of diastolic function assessment for predicting long-term survival in patients with myocardial infarction and preserved or mildly reduced left ventricular ejection fraction (LVEF >40%). The study included 2,234 consecutive patients with myocardial infarction who underwent coronary angiography in a single tertiary-level referral center between 2013 and 2021. Echocardiography was performed within 24 hours of admission and diastolic function was assessed using current ASE/EACVI guidelines. Results indicated that significant diastolic dysfunction, defined as grade II and III, was independent predictor for all-cause mortality (hazard ratio [HR] = 2.01; 95% CI, 1.37-2.94; P < 0.001) in multivariable model incorporating other significant clinical, angiographic and echocardiographic predictors. The individual diastolic parameters (average E/e’, tricuspid regurgitation velocity and left atrial volume index) were also independent predictors of all-cause mortality. However, the single models were inferior to the model that included significant diastolic dysfunction. The study concluded that significant diastolic function was a strong predictor of cardiac mortality in patients with myocardial infarction with LVEF>40%. Additionally, an aggregate assessment of diastolic function using the guideline-recommended algorithms was superior to any of the individual parameters for assessing diastolic function.

Keywords: echocardiography, diastolic function, myocardial infarction, survival

Lay summary: This study examined the echocardiographic assessment of diastolic function in patients with myocardial infarction to determine its impact on survival. Over 2,000 patients with myocardial infarction had echocardiography early after admission to the hospital. The results showed that patients with myocardial infarction who had significant diastolic disfunction had 2 times higher risk for death than other patients in this study. The parameters of diastolic disfunction were better at finding people who had a high risk of death compared to other clinical and echocardiographic parameters. This means doctors can more confidently identify patients after myocardial infarction at high risk of death and who needs more tests and more aggressive treatment.

Dobutamine stress echocardiography-detected ischemia predicts efficacy of PCI

Ahmed-Jushuf F, Foley MJ, Rajkumar CA, et al.

Ischemia on Dobutamine Stress Echocardiography Predicts Efficacy of PCI: Results From the ORBITA-2 Trial.

J Am Coll Cardiol 2025; 85:1740-1753; https://doi.org/10.1016/j.jacc.2025.02.034

Previously, the results of the ORBITA-2 (The Placebo-Controlled Trial of Percutaneous Coronary Intervention for the Relief of Stable Angina) trial revealed that percutaneous coronary intervention (PCI) relieved angina in patients with single-vessel and multivessel stable coronary artery disease (CAD) on little or no antianginal medication. This secondary analysis of ORBITA-2 investigates the relationship between ischemia, assessed by dobutamine stress echocardiography (DSE), and the placebo-controlled efficacy of PCI. The analysis included patients with angina, single- or multivessel CAD and ischemia, all of whom underwent antianginal medication washout and were evaluated prerandomization using the ORBITA-app, questionnaires, DSE, and exercise treadmill testing. Stress echocardiography scores were calculated for each left ventricular segment at peak stress, with normal, hypokinetic, akinetic, dyskinetic, and aneurysmal segments scoring 0 to 4, respectively. Among the 262 patients with available DSE data (median age 65.5 years; 79.4% male), the median baseline stress echocardiography score was 1.25 (IQR: 0.33–2.92), with a median score of 1.42 in the PCI group (n=133) and 1.00 in the placebo group (n=129). Higher stress echocardiography scores were strongly associated with greater placebo-controlled improvements in angina symptom scores following PCI (OR: 1.23; 95% credible interval [CrI]: 1.13–1.35; Pr(interaction)>99.9%). Elevated scores also predicted a significant reduction in the frequency of daily angina episodes (OR: 1.36; 95% CrI: 1.24–1.49; Pr(interaction)>99.9%), along with notable improvements in the Seattle Angina Questionnaire (SAQ) angina frequency score (mean difference: 8.22; 95% CrI: 0.96–15.50; Pr(interaction)=98.7%) and quality of life score (mean difference: 8.95; 95% CrI: 2.05–16.00; Pr(interaction)=99.3%). Importantly, the association between stress echocardiography scores and reduction in daily angina episodes remained consistent, regardless of baseline symptom characteristics. The authors concluded that in patients with single- or multivessel stable CAD receiving little or no antianginal therapy, the placebo-controlled efficacy of PCI was predicted by the extent of ischemia identified on DSE. Greater baseline ischemic burden was associated with more substantial improvements in both symptoms and quality of life following PCI.

Keywords: coronary artery disease; ischemia; percutaneous coronary intervention; stress echocardiography.

Lay summary: A previous study (ORBITA-2) showed that a procedure called PCI, used to open obstructed coronary arteries, can relieve chest pain (angina) even in patients taking little or no heart medication. This new analysis looked at whether a heart imaging study called dobutamine stress echocardiography (DSE) could predict who benefits most from PCI. Among 262 patients with coronary artery disease, those with more signs of reduced blood flow on the scan had greater improvements in symptoms and quality of life after the procedure. The more severe the initial blood flow problem, the more relief they experienced—regardless of how bad their symptoms seemed at the start.

The distance between the anterior papillary muscle and the interventricular septum is associated with mid-ventricular obstruction in hypertrophic cardiomyopathy

Xiao M, Wang J, Nie C, et al.

Distance Between the Anterior Papillary Muscle and Interventricular Septum Evaluated by Echocardiography to Diagnose Mid-ventricular Obstruction in Hypertrophic Cardiomyopathy

J Am Soc Echocardiogr 2025; 6:S0894-7317(25)00230-5; https://doi.org/10.1016/j.echo.2025.04.018

Left ventricular mid-ventricular obstruction (MVO) is thought to be dynamic with hypertrophic cardiomyopathy (HCM). Therefore, the distance between the anterior papillary muscle and interventricular septum was employed as a parameter named APM-IVS distance for assessing MVO by rest echocardiography. MVO was defined as a mid-ventricular gradient of ≥ 30 mmHg at rest or after being provoked. APM-IVS distance was analyzed on apical three chamber view at end-diastole.

A total of 2125 patients with HCM were enrolled in this study. Among these, data from 1453 patients with measurable APM-IVS distances were analyzed. Of the 1453 patients, 596 had MVO, while 857 did not exhibit MVO. APM-IVS distance demonstrated the highest diagnostic accuracy in identifying MVO, exhibiting an area under the receiver operating characteristic curve of 0.949 (95% CI: 0.937–0.960). The presence of a smaller APM-IVS distance was correlated with increased incidence of left ventricular apical aneurysm and MVO, elevated levels of N-terminal pro brain natriuretic peptide, as well as higher New York Heart Association functional class.

As conclusion, a small APM-IVS distance was associated with MVO, which was alleviated after myectomy following an increase in APM-IVS distance.

Keywords: echocardiography; hypertrophic cardiomyopathy; mid-ventricular obstruction; papillary muscle; interventricular septum.

Lay summary: In patients with hypertrophic cardiomyopathy (HCM), a condition where the heart muscle thickens, a small APM-IVS distance (the space between a specific heart muscle and the wall separating the heart's chambers) is linked to a blockage in the heart's pumping chamber. This blockage, called mid-ventricular obstruction (MVO), can be reliably identified by measuring this distance using an ultrasound of the heart. The study found that a smaller APM-IVS distance meant a higher chance of MVO and worse symptoms. Importantly, after surgery to relieve the obstruction, the APM-IVS distance increased, and the MVO significantly improved. This suggests that the APM-IVS distance is a useful tool for diagnosing and monitoring MVO in HCM patients.

Elderly women with primary calcified mitral valve disease and patients with secondary mitral regurgitation are the most common phenotypes of patients rejected for mitral valve interventions

Ludwig S, Coisne A, Hamzi K, et al; CHOICE-MI Investigators

Phenotypic Clustering Analysis of Patients Rejected for Mitral Valve Interventions: Implications for Future Transcatheter Technologies.

Eur Heart J Cardiovasc Imaging 2025; jeaf141; https://doi.org/10.1093/ehjci/jeaf141

The authors aimed to analyze the phenotypic characteristics of surgical high-risk patients ineligible for mitral valve (MV) interventions using an unsupervised phenotypic clustering approach. Between 2014 and 2022, the CHOICE-MI registry included 984 patients with MR undergoing screening for transcatheter mitral valve replacement at 33 international sites. For this study, only patients with screening failure receiving medical therapy alone were included. Patients receiving transcatheter or surgical treatment were excluded. A cluster analysis using K-means was performed on baseline clinical, demographic, and imaging variables to identify different patient phenotypes.

Among 284 patients with MR (77.4±8.82 years, 56.0% female, EuroSCORE II: 6.6±5.8%) considered ineligible for any MV intervention, two clinically distinct phenogroups (PG) were identified using unsupervised hierarchical clustering of principal components. PG1: elderly women with primary MR, preserved left ventricular function, and annular calcification; and PG2: patients with secondary MR, advanced heart failure, and high prevalence of comorbidities. One-year all-cause mortality did not differ between the phenogroups (PG1: 21.4%, PG2: 23.4%, p=0.89). Predictors of mortality were albumin, renal function, extracardiac arteriopathy for PG1, and albumin, coronary artery disease, and prior myocardial infarction for PG2.

This study identified two major subgroups among patients ineligible for mitral interventions showing profound differences in clinical and anatomical profiles. Identifying these factors may drive technological evolution to address the unmet clinical need for therapeutic options in MR patients.

Keywords: echocardiography; mitral valve; transcatheter interventions; structural heart disease.

Lay summary: A large registry of 984 patients with mitral regurgitation aimed to analyse phenotypes of surgical high risk patients ineligible for mitral valve interventions. These were divided into two groups: elderly women with primary mitral regurgitation, preserved left ventricular function, and annular calcification and patients with secondary mitral regurgitation, advanced heart failure, and high prevalence of comorbidities. One year all-cause mortality did not differ between the groups.

Atrial right to left shunt after Tetralogy of Fallot repair is associated with better atrial function

Delaney MA, Bennett L, Faerber JA, et al.

Atrial Right to Left Shunting after Tetralogy of Fallot Repair is Associated with Improved Atrial Function and Shorter Hospital Length of Stay - An Echocardiographic Cohort Study.

J Am Soc Echocardiogr 2025; S0894-7317(25)00232-9; https://doi.org/10.1016/j.echo.2025.04.020

Atrial right to left (aRL) shunting is often identified on echocardiograms in the early postoperative period following repair of tetralogy of Fallot (TOF) and thought to reflect poor right ventricular (RV) compliance, but to be possibly beneficial in serving as a “pop off” for the RV. The authors aimed to investigate the relationship between aRL shunting to echocardiographic diastolic function and early postoperative outcomes, hypothesizing that aRL would be associated with worse diastolic function, and with post-operative length of stay (LOS).

One hundred ninety-seven TOF patients were included. Patients were grouped as “elective” if repaired after 30 days of age without prior palliation, “staged” if they had a neonatal palliation prior to repair, or as “neonatal” repair if repaired <30 days age. In the overall cohort, aRL was present in 68 patients (35%) and was associated with lower right atrial (RA) end diastolic volume, higher RA emptying fraction, higher A wave peak velocity, and higher RA peak longitudinal strain. In the subgroup analysis, aRL was associated with higher RA emptying fraction, peak longitudinal strain and shorter LOS in the elective repair group only.

Atrial right to left shunt after TOF repair was associated with better atrial function, and possibly with a combination of robust atrial function in the presence of RV noncompliance, and shorter LOS in patients undergoing elective TOF repair, but not in those undergoing a neonatal intervention.

Keywords: echocardiography; congenital; shunt; tetralogy of Fallot

Lay summary: After surgery to fix a heart defect called tetralogy of Fallot (TOF), doctors often see a small hole between the heart's upper chambers where blood flows from the right side to the left (called aRL shunting). It was thought this shunting might be a sign of a stiff right pumping chamber and could even be helpful. This study looked at 197 patients and found that aRL shunting was present in about a third of them. Surprisingly, instead of being linked to a stiffer heart, it was associated with better function of the right upper heart chamber. For patients who had their surgery electively (meaning not as newborns or after an earlier procedure), having this shunting was even linked to a shorter hospital stay after surgery. This suggests aRL shunting might not always be a bad sign and could even be a sign of a healthier heart response in some patients.

Lee H-J, Singh A, Lim J, et al.

Diffuse Interstitial Fibrosis of the Myocardium Predicts Outcome in Moderate and Asymptomatic Severe Aortic Stenosis

JACC Cardiovasc Imaging 2025;18:180-19; https://doi.org/10.1016/j.jcmg.2024.08.003

This multicenter, prospective cohort study evaluated the prognostic value of myocardial fibrosis, as quantified by extracellular volume fraction (ECV%) and by late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR), in 457 patients with moderate aortic stenosis (AS; n=176) or asymptomatic severe AS (n=281). Over a median follow-up of 5.7 years, the primary composite endpoint—all-cause mortality or unplanned admission for heart failure—occurred in 83 patients. The cohort had a mean age of 68.5 years and was predominantly male (67%). Median ECV% was 26.6%, and LGE was present in 31.5% of patients. Severity of AS did not correlate with ECV% or LGE, but higher ECV% were independently associated with worse outcomes in multivariable analysis (adjusted HR 1.05 per 1% increase in ECV%; 95% CI: 1.02–1.11; P=0.039). Other imaging parameters, such as lower aortic valve area and higher LGE percentage, were also associated with adverse events. Clinical factors linked to higher ECV% included female sex, higher NYHA functional class, worse renal function, diastolic dysfunction, and elevated NT-proBNP. The study demonstrates that CMR-based assessment of myocardial fibrosis provides incremental prognostic value over conventional risk factors, highlighting its potential to identify higher-risk patients who may benefit from closer surveillance. Whether earlier intervention in these high-risk patients improves clinical outcomes remains to be determined.

Keywords: CMR; aortic stenosis; prognosis; diffuse interstitial fibrosis; late gadolinium enhancement

Lay summary: Current guidelines suggest aortic valve replacement for people with severe, symptomatic aortic stenosis (AS), but recommend careful monitoring for those with moderate AS or severe AS without symptoms. This study looked at 457 patients with moderate or severe but asymptomatic AS to see if heart muscle damage (interstitial fibrosis), measured by cardiac magnetic resonance (CMR), is associated with heart failure or death. The results showed that patients who experienced these events had more cardiac damage, regardless of other health factors. This means doctors may use CMR to identify patients at higher risk who could benefit from closer follow-up, even if they do not yet have symptoms. CMR could help personalize care and improve outcomes for people with aortic stenosis.

Non-invasive estimation of pressure volume loops using cardiovascular magnetic resonance predicts adverse remodeling after myocardial infarction

Lav T, Engstrøm T, Kyhl K, et al.

Non-invasive pressure volume loops provide incremental value to age, sex, and infarct size for predicting adverse cardiac remodeling after ST-elevation myocardial infarction.

Eur Heart J - Imaging Methods Practice 2025; qyaf008: https://doi.org/10.1093/ehjimp/qyaf008

This study aimed to assess the predictive value of non-invasive pressure volume (PV)-loop variables by cardiovascular magnetic resonance (CMR) for determining adverse remodeling after ST-elevation myocardial infarction (STEMI). In total, 181 STEMI-patients from the Third DANish Study of Optimal Acute Treatment of Patients with STEMI (DANAMI-3) study underwent CMR during index hospitalization and at 3-months follow-up. A time-varying elastance model for generating PV-loops from CMR volumetry and brachial blood-pressure was used to calculate contractility, arterial elastance, stroke work, potential energy, efficiency, external power, ventriculoarterial coupling, and energy per ejected volume. PV-loop variables showed recoupling and favorable cardiac energetics at follow-up compared to baseline. Adverse remodeling was seen in 28 patients (15%), defined as a concomitant increase in end-diastolic- and end-systolic volume of ≥12% from baseline to follow-up. Pressure volume loop variables measured at baseline (contractility and efficiency) showed predictive value for adverse remodeling, independent of age, sex and infarct size (IS). Females showed a higher increase in contractility during follow-up. A higher energy expenditure was seen at baseline in LAD-infarctions compared to LCx- and RCA-infarctions. In conclusion, non-invasive PV-loop variables by CMR have incremental predictive value to age, sex, and IS for determining development of adverse cardiac remodeling in STEMI patients treated with primary PCI. Furthermore, the PV-loop variables show significant differences in post-infarct cardiovascular adaptation between sexes and culprit vessels.

Keywords: CMR; MRI; STEMI; pressure volume loop; adverse remodeling; contractility; elastance; stroke work

Layperson summary: This study explored whether non-invasive heart function measurements assessed by cardiac MRI after a heart attack (STEMI) could predict harmful changes in the heart's size and shape (adverse remodeling) three months later.  Researchers analyzed data from 181 STEMI patients.  They noninvasively calculated pressure-volume loops from the MRI scans and blood pressure readings. They found that two measures, contractility (how strongly the heart contracts) and efficiency (how well the heart uses energy), taken at the time of the heart attack, were predictive of adverse remodeling, even after considering age, sex, and the size of the damaged heart muscle.  They also observed differences in how men and women, and different types of heart attacks, adapted after the event.  Essentially, these non-invasive measures appear to be useful tools for identifying patients at risk for negative heart changes after a STEMI.

Direct mitral regurgitation quantification using four-dimensional flow cardiovascular magnetic resonance: which is the best measurement plane?

Aratikatla A, Safder T, Ayuba G , et al.

Impact of measurement location on direct mitral regurgitation quantification using four-dimensional flow cardiovascular magnetic resonance

J Cardiovasc Magn Reson 2025; 27:101847; https://doi.org/10.1016/j.jocmr.2025.101847

Four-dimensional flow CMR (4D flow CMR) can be useful to grade mitral regurgitation (MR) severity, through direct quantification of MR Regurgitation Volume (RVol) either through an indirect approach (using volumetric calculations) or through a direct measurement analysing the momentum profile of the MR jet (RMomjet). However, the plane position is a key factor for accurate results. This study assessed 45 patients with diverse mechanisms of MR (primary 26.7%, secondary 55.6%, mixed 20% and post-mitral valve repair 4.4%), classified as 28.9% grade 1, 53.3% grade 2 and 17.8% grade 3+. Measurement planes were shifted along the MR jet towards the left ventricle (LV) or left atrium (LA) and changes in RVol and RMomjet relative to measurement at the location of the peak velocity focused on patients with more than mild MR. Moving the measurement point further into the LA resulted in a continuous increase in RVol and overestimation of RVol, with more patients classified as having severe MR (grade 1 MR decreased from 91% to 71%; grade 3 MR increased from 4% to 18%). When RVol was measured furthest upstream, it was significantly lower (-39%), highlighting the significant impact of measurement location. The RMomjet decreased gradually when measured from the LA until the peak velocity location. However, it remained statistically unchanged after the peak velocity location, suggesting that the positioning of the plane at the peak velocity location may be optimal to estimate of RVol using the direct 4D flow CMR approach.

Keywords: CMR; mitral regurgitation; 4D flow; regurgitant volume; regurgitant jet flow momentum.

Layperson summary: This study explored how the placement of a measurement plane affects the accuracy of measuring mitral regurgitation (MR) using a special type of magnetic resonance sequence called 4D flow MRI. Researchers measured the amount of blood leaking back through the valve (regurgitant volume) at seven different locations along the leak jet. They found that the measured regurgitant volume changed significantly depending on where they placed the measurement plane. Measurements taken further downstream (into the left atrium) showed higher volumes, while measurements taken further upstream (closer to the left ventricle) showed lower regurgitant volumes. However, when they looked at the momentum of the leaking blood, they found that it stabilized at the point of peak velocity of the leak jet. This suggests that measuring the regurgitant volume at the point of peak velocity, provides the most consistent and likely the most accurate measurement. This finding is important for improving the accuracy of MR assessments using 4D flow MRI.

Myocardial disarray and extracellular volume across hypertrophic cardiomyopathy stages associate with ECG markers of arrhythmic risk

Ashkir Z, Samat AHA, Ariga R, et al.

Myocardial disarray and fibrosis across hypertrophic cardiomyopathy stages associate with ECG markers of arrhythmic risk.

Eur Heart J Cardiovasc Imaging 2025; 26:218-228; https://doi.org/10.1093/ehjci/jeae260

Diffusion tensor cardiac magnetic resonance (DT-CMR) can evaluate myocardial tissue integrity in hypertrophic cardiomyopathy (HCM) by measuring water molecule diffusion. It derives fractional anisotropy (FA) and mean diffusivity (MD), indicating water molecule alignment and diffusion magnitude, respectively, which serve as surrogates for myocardial disarray. This study assessed FA and MD and their relationship to ventricular repolarization anomalies in 24 HCM patients, 24 sarcomere-positive genotype patients without hypertrophy (SARC+LVH−), and 14 matched controls. The results demonstrated a graded progressive decline in FA across groups with FA significantly lower in HCM group, even after adjusting for extracellular volume (0.49 ± 0.05 for HCM; 0.52 ± 0.04 for SARC+LVH−; 0.53 ± 0.04 controls). In a segmental analysis, reduction was seen in 25% of SARC+LVH− patients without a specific pattern and in 54% of HCM patients, mainly in anteroseptal segments. Electrocardiographic JTc interval was significantly prolonged in both SARC+LVH- and HCM patients and there was a pronounced inverse correlation between FA and JTc in the SARC+LVH− group, and less in the HCM, indicating a potential link between structural abnormalities and electrical remodeling. MD was increased in both HCM and SARC+LVH− groups compared to controls (p=0.007) and both JTc and QTc intervals correlated significantly in the HCM group. DT-CMR showed that low FA was observed in both groups HCM and SARC+LVH−, suggesting myocardial disarray is present in early stages of disease and correlates with repolarization abnormalities and disease activity.

Keywords: CMR, diffusion tensor cardiac magnetic resonance (DT-CMR), Myocardial disarray hypertrophic cardiomyopathy

Layperson summary: This study used special heart scans (diffusion tensor cardiac MRI) to look at the heart muscle structure in people with hypertrophic cardiomyopathy (HCM), a condition where the heart muscle thickens, and in people who carry a gene variant linked to HCM but don't yet have the thickened muscle (SARC+LVH-). The researchers wanted to see if there were changes in the heart's structure, called myocardial disarray, and if these changes were related to electrical activity in the heart that could increase the risk of dangerous heart rhythms. They found that both HCM patients and gene variant carriers had areas of disorganized heart muscle, even before the muscle thickened. They also found that both groups had changes in their heart's electrical activity. In the gene variant carriers, the disorganization of the heart muscle was linked to these electrical changes. These findings suggest that these scans and electrical measurements could be useful for identifying people at risk for HCM-related problems, even before they develop the full-blown disease. 

Non-invasive estimation of left ventricular diastolic function using cardiovascular magnetic resonance and echocardiography

Hauge-Iversena IM, Nordéna ES, Mellebyb AO, et al.

Non-invasive estimation of left ventricular chamber stiffness using cardiovascular magnetic resonance and echocardiography.

Journal of Cardiovascular Magnetic Resonance 2025, 27:101849, https://doi.org/10.1016/j.jocmr.2025.101849

This study explored the ability of several imaging biomarkers of diastolic function from cardiovascular magnetic resonance (CMR) and echocardiography in predicting the slope of the end-diastolic pressure-volume relationship (EDPVR) in rats. The Authors included 38 Sprague Dawley rats with diastolic dysfunction (induced by surgical aortic constriction) and 9 healthy controls. From CMR, native T1 values, peak early diastolic longitudinal strain rate (SRe(long)) and E/SRe(long), left atrial (LA) ejection fraction, isovolumetric relaxation time (IVRT), E/A and peak LA strain, correlated best with the EDPVR slope (|r|=0.54–0.72). From echocardiography, E/A, E, LA diameter, e’/a’, E/SRe(long) and IVRT correlated with the EDPVR slope (|r|=0.49–0.67), while E/e’, e’ and E-wave deceleration time demonstrated poor correlation (|r|=0.17–0.27). Receiver operating characteristics analysis indicated better performance of CMR imaging biomarkers than echocardiography in predicting increased EDPVR slope. This study identifies several imaging biomarkers obtained from both echocardiography and CMR that are able to estimate LV chamber stiffness non-invasively, providing an important tool for future mechanistic research on myocardial stiffness.

Keywords: Imaging biomarkers; CMR; MRI; echocardiography; Preclinical research; Diastolic function; Chamber stiffness

Layperson summary: This study investigated how well imaging techniques (echocardiography and cardiac MRI) can predict left ventricular (LV) chamber stiffness in rats.  LV stiffness is important in heart disease, and preclinical research needs reliable ways to measure it.  Researchers compared various measurements from these imaging techniques to the "gold standard" measurement of LV stiffness (the slope of the end-diastolic pressure-volume relationship, or EDPVR).  They found that some measurements, particularly those related to the left atrium and mitral valve flow, correlated reasonably well with the EDPVR slope.  While some commonly used measurements were not helpful, this research identifies promising imaging biomarkers that could be valuable tools for future studies exploring the mechanisms of myocardial stiffness.  MRI-derived measures generally performed better than those from echocardiography.

Non-invasive identification of acute cardiac allograft rejection using multiparametric cardiac magnetic resonance

Zhou P, Dong Z, Hu X, et al.

Incremental Value of Multiparametric Cardiac MRI for Non-invasive Identification of Significant Acute Cardiac Allograft Rejection: a Prospective and Biopsy-proven Study.

Eur Heart J Cardiovasc Imaging 2025; jeaf052; https://doi.org/10.1093/ehjci/jeaf052

This study investigated the accuracy of cardiac magnetic resonance (CMR) to identify significant acute cardiac allograft rejection (SR) and its incremental value over conventional serum biomarkers. Heart transplantation (HTx) recipients with endomyocardial biopsy and healthy controls were prospectively recruited. CMR feature tracking (CMR-FT) was performed to evaluate the left ventricular (LV) global strain in all three directions. Participants were divided into 3 groups: 30 controls, 23 SR (acute cellular rejection grade≥2R and/or antibody-mediated rejection [AMR] grade≥pAMR1), and 28 NSR (non-SR). Compared with NSRs, SRs showed elevated natriuretic peptides (NTproBNP), worse LV global longitudinal strain (GLS) (-9.7±3.1% vs -13.1±2.9%, p<0.001), increased native T1 (1384±80.1ms vs 1321±69.9ms, p<0.001) and T2 values (50.9±2.7ms vs 45.7±4.3ms, p<0.001). In multivariable analysis, GLS and T2 value were independently associated with SR after NT-proBNP adjustment. The Authors concluded that GLS and T2 value were independently associated with SR, providing incremental value for non-invasive identification of significant rejection in HTx recipients.

Keywords: CMR; MRI; cardiac transplant; allograft rejection; T1; T2; ECV; global longitudinal strain; feature tracking

Layperson summary: This study explored whether cardiac MRI (CMR) could improve the detection of significant acute rejection after heart transplantation. Researchers compared CMR scans and standard blood tests (including NT-proBNP) in heart transplant recipients with and without rejection, as well as healthy individuals. They specifically looked at measures of heart muscle strain (GLS), and tissue characteristics (including T1 and T2 values). The study found that worse GLS and higher T2 values were linked to significant rejection, even after accounting for NT-proBNP levels. Importantly, adding GLS and T2 measurements to the standard blood test improved the ability to identify patients experiencing rejection. This suggests that CMR may be a valuable non-invasive tool for detecting rejection after heart transplantation.

Baggiano A, Baessato F, Mushtaq S, et al.

 STress computed tomogRaphy perfusion and stress cArdiac magnetic resonance for ThE manaGement of suspected or known coronarY artery disease: resources and outcomes impact.

J Cardiovasc Comput Tomogr 2024; 18:553-558; https://doi.org/10.1016/j.jcct.2024.08.001

This study compared coronary CT angiography plus stress CT perfusion (CCTA + Stress-CTP) and stress cardiovascular magnetic resonance (Stress-CMR) in symptomatic patients with suspected or known coronary artery disease (CAD). A total of 624 patients with intermediate to high pretest likelihood of CAD or prior revascularization were enrolled, with 223 undergoing CCTA + Stress-CTP and 401 undergoing Stress-CMR. Follow-up at 1 year assessed all cardiac events (revascularization, non-fatal MI, and death) and hard cardiac events (non-fatal MI and death). Revascularization rates were higher in the CCTA + Stress-CTP group (29%) compared to the Stress-CMR group (7%). Hard cardiac events were rare with both strategies (0.4% in CCTA + Stress-CTP vs. 3% in Stress-CMR). The CCTA + Stress-CTP group had a higher overall cardiac event rate but lower incidence of hard cardiac events. Cumulative costs were €1,970 ± 2,506 for CCTA + Stress-CTP and €733 ± 1,418 for Stress-CMR. These findings suggest that CCTA + Stress-CTP leads to higher revascularization rates but similar low hard event rates compared to Stress-CMR, with higher associated costs.

Keywords: Cardiac magnetic resonance; Computed tomography perfusion; Coronary artery disease; Coronary computed tomography angiography; Major adverse cardiac events

Lay summary: This study compared two heart imaging tests, CCTA + Stress-CTP and Stress-CMR, in patients with chest pain or a history of heart disease. CCTA + Stress-CTP combines a coronary CT angiography scan to examine for blocked arteries and a Stress CT test to assess heart function under stress, while Stress-CMR uses MRI to assess heart function under stress. More patients who had CCTA + Stress-CTP needed treatment procedures (29% vs. 7%), but both tests showed low rates of heart attacks and deaths. While CCTA + Stress-CTP led to more follow-up treatments, serious complications were rare for both tests, though it was the more expensive option.

Statin therapy impact on pericoronary adipose tissue attenuation, marker of coronary inflammation, assessed by serial cardiac computed tomography

Cheng K, Hii R, Lim E, et al.

Effect of statin therapy on coronary inflammation assessed by pericoronary adipose tissue computed tomography attenuation.

European Heart Journal - Cardiovascular Imaging 2025; 26:784–793; https://doi.org/10.1093/ehjci/jeaf062

The study aimed to assess the temporal changes in pericoronary adipose tissue (PCAT) attenuation per lesion on coronary computed tomography angiography (CCTA) in patients treated with statin therapy versus those not receiving statins. In total, 96 stable patients were studied who had clinically indicated serial CCTA with >12 months apart with a median follow-up 3.8 years. The patients were divided in 3 groups according to the statin treatment. Those who started statin treatment based on the CCTA findings (n=26) had a significant reduction in PCAT (−79.4 ± 11.7 to −86.5 ± 10 HU, P < 0.001) at the 2nd CCTA. The patients who were treated with statins at the 1st CCTA and continued (n=34) had also significant reduction in PCAT (−83.5 ± 8.5 to −90.6 ± 8.5 HU, P = 0.001) at the 2nd CCTA. However, the patients who never received statins (n=34) and were statin-naïve at both time-points undergoing CCTA had no significant difference in PCAT (−84.4 ± 9.7 to −86.6 ± 9.5, P = 0.1). Statin intensity and LDL reduction were independently associated with the change of PCAT. In conclusion, the patients who were treated with statins had significant reduction of PCAT, indicating less pericoronary inflammation and response to statin-treatment.

Keywords: CT; CCTA; statins; pericoronary adipose tissue; LDL; response to treatment

Lay summary: Pericoronary adipose tissue attenuation on CCTA is an indication of coronary inflammation. Statins are known to have pleiotropic effects and anti-inflammatory action. The current study demonstrated that patients who were receiving statins had significant reduction in the pericoronary adipose tissue attenuation on serial CCTA more than 12-months apart. Patients who were treated with more intense statins or achieved lower LDL levels achieve higher % pericoronary adipose tissue attenuation reduction. This is indicative that statins reduced the coronary inflammation and the stronger the statin, the better the result, proving the benefit of the statin treatment directly on the coronary arteries. Moreover, this CCTA parameter could be used to monitor the response of the coronary arteries to statin treatment and allow us to guide a more personalized treatment.

Quantification of atherosclerotic coronary plaques on cardiac CT with AI is associated with a higher relative risk in women: data from the CONFIRM2-Registry

Feuchtner GM; Lacaita PG; Bax JJ, et al.

AI-Quantitative CT Coronary Plaque Features Associate with a Higher Relative Risk in Women: CONFIRM2-Registry.

Circ Cardiovasc Imaging 2025;  https://doi.org/10.1161/CIRCIMAGING.125.018235

The multicenter study aimed to assess gender differences in the atherosclerotic coronary plaques quantified by AI on coronary computed tomography (AI-QCT) and to associate these differences with major adverse cardiovascular events (MACE) i.e. death, myocardial infarction, late revascularization, cerebrovascular events, unstable angina and congestive heart failure. The study included 3551 patients who were referred for cardiac CT with the suspicion of coronary artery disease. During 4.8±2.2 years of follow-up, MACE occurred in 3.2% of women and 6.1% of men. Men had higher total plaque volume (TPV), noncalcified plaque (NCP), calcified plaque (CP), percentage atheroma volume (PAV) and more prevalent high-risk plaque (HRP) as defined by AI-QCT. However, independent of age and cardiovascular risk factors, the AI-QCT features were related with higher relative risk of MACE in women than men. For every 50 mm3 increase in TPV the relative risk increased in women by 17.7% vs 5.3% in men, for NCP the relative risk increased by 27.1% vs 11.6%, for CP by 22.9% vs 5.4%, respectively (p-interaction <0.005 for all). Similarly, for PAV the risk was higher in women. The findings remained unchanged when restricted to a secondary composite endpoint (death and myocardial infarction). In conclusion, the AI-QCT coronary plaque features TPV, NCP, CP, PAV although more prevalent in male, were associated with higher relative risk of MACE in women. Hence, these AI-QCT features in women may prompt more aggressive anti-atherosclerotic therapy and more early preventive interventions. AI-QCT plaque features should be integrated into existing risk-scores to enhance their accuracy.

Keywords: CT; CCTA; sex differences; gender; women; AI; QCT

Lay summary: Coronary atherosclerotic plaques can recently be quantified on coronary computed tomography by AI (AI-QCT). Men have higher total plaque volume (TPV), noncalcified plaque (NCP), calcified plaque (CP), and percentage atheroma volume (PAV) than women, and they have more adverse cardiac events (MACE) 6.1% vs 3.2%, respectively. However, all the aforementioned AI-QCT parameters are associated with higher relative risk of MACE in women than in men, independent of age and cardiovascular risk factors. In details, for every 50mm3 increase in TPV, NCP and CP the relative risk of MACE significantly increased in women vs men by 17.7% vs 5.3%, by 27.1% vs 11.6%, and by 22.9% vs 5.4%, respectively. These data from a multicenter study, the CONFIRM2 registry, indicate that in women with atherosclerosis and these AI-QCT features, more intensive anti-atherosclerotic therapy has to be applied and more early preventive treatment, since the relative risk of MACE is higher than in men.

Progression of coronary artery calcifications in asymptomatic patients

Sung DE, Lee MY, Lee JY, et al.

Coronary artery calcification distribution and progression in over 70 000 asymptomatic individuals: implications for assessment intervals and optimal testing age.

Eur Heart J Cardiovasc Imaging 2025; jeaf100; https://doi.org/10.1093/ehjci/jeaf100

This study assessed the prevalence and progression of coronary artery calcifications (CAC) in a retrospective cohort of 70,389 asymptomatic individuals aged over 30 years from Korea, with at least two CAC score assessments (2010-22). Among participants (mean age 40.5 ± 6.6 years; 87% men), 84% had a baseline CAC score of 0, and 3% had scores > 100. Notably, 93% of women had a CAC score of 0, with the highest percentages observed in younger women. Incident CAC developed in 16% of participants with an initial score of 0 within five to six years, with just 1% exceeding score of 100. Extended follow-up data showed a consistently low prevalence of significant CAC scores, with only 4% exceeding scores > 100 after 10 years.

Overall, the study showed that, in a large Korean cohort of over 70 000 asymptomatic adults, most had baseline CAC = 0, indicating low subclinical atherosclerosis; significant calcification (CAC > 100) developed very rarely both within 5-6 years (1%) and within 10 years (4%).

Keywords: CT; coronary calcification; asymptomatic

Lay summary: This study looked at how common and how quickly calcium builds up in the heart's arteries (called CAC, or Coronary Artery Calcium) in over 70,000 healthy Korean adults. A CAC score of 0 means no calcium is seen, indicating a very low risk of heart disease. The researchers found that most participants (84%) initially had a CAC score of 0, especially younger women (93%). Over five to six years, only a small percentage (16%) developed new calcium deposits, and even fewer (1%) had a significant amount (CAC score above 100). After 10 years, still only a small number of people (4%) had a significant CAC score. This suggests that in healthy adults, especially those without symptoms, significant atherosclerosis is uncommon, and a zero CAC score often remains nearly unchanged for a long time.

Cardiac computed tomography for ruling out ischaemic heart disease in new-onset heart failure

Graversen CB, Rasmussen LD, Sundbøll J, et al.

Clinical Likelihood Prediction of Hemodynamically Obstructive Coronary Artery Disease Cardiac computed tomography for ruling out ischaemic heart disease in new-onset heart failure

Eur Heart J Cardiovasc Imaging 2025; 26:794–801; https://doi.org/10.1093/ehjci/jeaf090

This study evaluated the use of cardiac computed tomography (CT), including coronary artery calcium scoring (CACS) and coronary CT angiography (CCTA), as a non-invasive alternative to invasive coronary angiography (ICA) for excluding obstructive coronary artery disease (CAD) in patients with new-onset heart failure (HF). In a cohort of 3,336 patients, obstructive CAD was ruled out in 83.8% of those with complete cardiac CT. Notably, patients with a CACS of 0 had a very low prevalence of obstructive CAD, with only 1.2% diagnosed at follow-up ICA. Conversely, patients with a CACS ≥1000 showed a high prevalence (47.2%) of obstructive CAD. The results suggest that cardiac CT can safely exclude obstructive CAD in a large proportion of new-onset HF patients, potentially reducing the need for invasive procedures.

Keywords: CT; CCTA; heart failure; ischaemic heart disease; coronary artery calcium score; coronary angiography; coronary artery disease

Lay summary: This study showed that using heart CT scans to look for artery disease in patients who recently developed heart failure can help avoid invasive procedures. The scans measure calcium buildup and look at the arteries directly. If no calcium is found, the chance of serious artery blockage is very low. This means that for many patients, a simple CT scan could rule out heart artery disease safely, sparing them from more invasive and riskier heart tests.

AI-Driven Coronary Plaque Quantification for Enhanced Cardiovascular Risk Prediction

Dahdal J, Jukema RA, Maaniitty T, et al.

CCTA-Derived coronary plaque burden offers enhanced prognostic value over CAC scoring in suspected CAD patients.

Eur Heart J Cardiovasc Imaging 2025; 26:945–954; https://doi.org/10.1093/ehjci/jeaf093

This study assessed the prognostic value of coronary artery calcium (CAC) scoring versus coronary CT angiography (CCTA)-derived plaque quantification using artificial intelligence (AI) in patients with suspected coronary artery disease (CAD). Among 2,404 patients followed over a median of 7 years, AI-derived metrics like percent atheroma volume (PAV) and non-calcified plaque volume percentage (NCPV%) provided superior predictive power for adverse cardiovascular outcomes compared to CAC scores. In particular, NCPV% achieved the highest accuracy for predicting myocardial infarction. These results underline that comprehensive, AI-assisted plaque assessment offers enhanced risk stratification and highlights the limitations of relying solely on CAC scoring for prognostic evaluation.

Keywords: CT; CCTA; coronary artery disease; coronary artery calcium score; plaque burden; artificial intelligence; myocardial infarction

Lay summary: Researchers found that looking at the total buildup inside heart arteries using advanced AI technology gives doctors a better way to predict who will have heart problems like heart attacks, compared to traditional calcium scoring methods. The study followed patients for several years and showed that measuring the amount and type of plaque inside arteries offers more precise information about heart risks. This could lead to better prevention and treatment strategies for people at risk of heart disease.

Optimizing PET/CT for Detection of Small, Mobile Lesions in Bioprosthetic Valves Using a Realistic Valvular Phantom

Barton AK, Kwiecinski J, Hashimoto H, et al.

Imaging small dynamic lesions using positron emission tomography and computed tomography: an 18F-sodium fluoride valvular phantom study

Eur Heart J Imaging Methods Pract. 2025; 3:qyaf013; https://doi.org/10.1093/ehjimp/qyaf013

This study introduces a purpose-built cardiac phantom designed to simulate the physiological environment and dynamic motion of bioprosthetic aortic valves, enabling the evaluation of imaging protocols for 18F-sodium fluoride (18F-NaF) PET/CT. The authors aimed to optimize the detection and quantification of small, tracer-avid lesions representative of early bioprosthetic valve degeneration, a technically challenging task due to the small size and constant motion of valvular structures. Through controlled adjustments of tracer activity, acquisition time, and motion correction algorithms, the phantom enabled reproducible measurements of signal-to-noise and target-to-background ratios comparable to those achieved in clinical imaging of transcatheter aortic valve dysfunction. Application of motion correction significantly enhanced image quality and quantitative accuracy. This work provides a validated framework for refining PET/CT protocols in the assessment of valvular pathology, with implications for improved surveillance and risk stratification in patients with structural valve interventions.

Keywords: PET; 18F-sodium fluoride; bioprosthetic valve; CT; phantom imaging; valvular heart disease; multimodality imaging; motion correction

Lay summary: This study used a specially designed heart model to improve imaging of tiny problem areas in artificial heart valves. These areas can signal valve failure and are hard to detect because they move with each heartbeat. Researchers tested different settings using a radioactive tracer and PET/CT scanning to find the best way to see these small lesions. They also compared the results to scans from a real patient with a failing valve. The new model worked very well and allowed them to adjust the scanner for clearer images. This could help doctors detect valve problems earlier and more accurately, potentially avoiding complications for patients with valve replacements.

64-projection myocardial perfusion scintigraphy provides more precise results than 32-projection scintigraphy

Abedi SM, Ghadirzadeh E, Karimi H, et al.

A comparison between 64-projection and 32-projection myocardial perfusion scintigraphy

Eur Heart J Imaging Methods Pract 2024; 3:qyae142; https://doi.org/10.1093/ehjimp/qyae142

This study aimed at providing a comparative assessment of the accuracies of two different imaging protocols, one with 32 projections and another with 64 projections, for myocardial perfusion scintigraphy (MPS) with a dual-head conventional single-photon emission computed tomography (SPECT) camera. All the major imaging variables that can be obtained with SPECT-MPS were assessed, including both perfusion and functional (systolic and diastolic) LV parameters. The study included 69 patients with suspected coronary artery disease (CAD) undergoing a two-days imaging protocol, with sequential acquisitions (32 or 64 projections) performed in a randomized order. The main results showed no significant difference as well as excellent/good agreement between the acquisition protocols in either the stress or rest conditions. However, while perfusion variables (summed rest, stress, and difference scores), left ventricular (LV) volumes and ejection fraction were quite comparable between the two methods, diastolic parameters [namely the ‘peak filling rate’ (PFR) and the ‘time to peak filling rate’ (TTPF)] were higher with a 64-projection than with a 32-projection acquisition protocol. The study concludes that while lower-projection techniques could be adequate for routine clinical SPECT-MPS, a 64-projection protocol is preferable when precise evaluations of LV diastolic function are necessary.

Keywords: myocardial perfusion scintigraphy; diastolic function; SPECT acquisition protocol; 32-projections

Lay summary: While clinical guidelines generally recommend using a 64-projection view technique for SPECT-MPS, some do not specify a preference between 32-projection and 64-projection methods showing lack of consensus in this matter. The present study tested the possibility that performing conventional SPECT-MPS with a 32-projections acquisition might provide a comparative output that the conventional 64-projections imaging protocol. Accordingly, most of the imaging parameters (including perfusion and LV systolic functional data) were unaffected by the protocols, showing the possible value of a more time-efficient 32-projection acquisition for routine SPECT-MPS. Nevertheless, the assessment of LV diastolic functional parameters was significantly less precise with the 32-projection vs 64-projection acquisition, possibly due to the lower temporal resolution of the experimental protocol. This means that clinicians may possibly adjust imaging protocols specifications with conventional SPECT-MPS without expecting major changes in overall test’s output.

PET Imaging in Cardiac Sarcoidosis Patients without high-risk clinical features and normal CMR

Shuduyeva F, Bakker ALM, Akdim F, et al.

The role of FDG-PET/CT in assessing cardiac sarcoidosis with no high-risk cardiac features and normal CMR

Eur Heart J Cardiovasc Imaging 2025; 26:830-837; https://doi.org/10.1093/ehjci/jeaf074

This single-center retrospective study assessed the clinical yield of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging in 324 patients with biopsy-proven extracardiac sarcoidosis, no high-risk clinical features, and a normal cardiac magnetic resonance (CMR) study. High-risk features were defined as low left ventricular ejection fraction (<45 %), Mobitz II or III atrioventricular block, or sustained ventricular tachycardia.

There was a cardiac FDG uptake in 21% of patients, but the majority (94%) were ultimately classified as ‘unlikely CS’ by a multidisciplinary team. Notably, over half of those with FDG uptake suggestive of CS were still deemed unlikely to have cardiac involvement after comprehensive clinical and imaging review. During a median follow-up of 3 years, adverse cardiac events were rare (annual risk 1%), and all five cardiac deaths occurred in the ‘unlikely CS’ group. A total of 7% of patients with cardiac FDG uptake experienced an event.

These findings suggest that FDG-PET/CT offers limited incremental value in patients with normal CMR without clinical high-risk features. The study supports a more selective approach to advanced imaging in sarcoidosis, reserving PET imaging for patients with either clinical or imaging indicators of cardiac involvement.

Keywords: Cardiac sarcoidosis; PET; CMR; inflammatory heart disease; Nuclear cardiology

Lay summary: Sarcoidosis is an autoimmune disease that can affect multiple organs. A Positron emission tomography (PET) scan is commonly used to detect possible heart muscle inflammation in patients with diagnosed sarcoidosis. This study included 324 patients with sarcoidosis in other parts of the body, but no heart symptoms or high-risk signs such as poor heart function or severe arrhythmias. All had normal heart magnetic resonance imaging (MRI) scans. A team of experts considered such patients unlikely to have serious inflammatory heart involvement after a comprehensive review. Over three years, serious heart problems were rare (1% risk per year). This study gives healthcare personnel greater confidence to use imaging tests more selectively. This would also result in a lower radiation dose received by this patient group.

PET/MR hybrid imaging comparison for ¹³N-ammonia perfusion and late gadolinium enhancement for the detection of myocardial scars

Heiniger PS, Igual GD, Galafton A, et al.

Impact of transmurality and location on the diagnostic performance of 13N-ammonia positron emission tomography in the detection of myocardial fibrosis – A hybrid positron emission tomography/magnetic resonance study

J Nucl Cardiol 2025; 47:102172; https://doi.org/10.1016/j.nuclcard.2025.102172

This study evaluates the diagnostic performance of ¹³N-ammonia positron emission tomography (PET) perfusion imaging for detecting myocardial scar compared to cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement as the reference standard. A total of 100 patients, of which 50 had coronary artery disease and 50 had prior myocarditis, underwent simultaneous PET/MR hybrid imaging.

PET had a high diagnostic accuracy for scar on a per-patient basis (sensitivity 84%, specificity 85%). However, segment-level sensitivity was significantly lower (53%). PET was more sensitive to more transmural scars and to subendocardial locations. Non-ischemic scars were more frequently missed. Furthermore, PET consistently underestimated the overall extent of fibrosis compared to CMR.

These findings highlight that while PET perfusion is effective for identifying patients with myocardial scar, it may underestimate non-ischemic scars. PET/MR hybrid imaging could increase the diagnostic yield of PET perfusion imaging. This study also underscores the diagnostic strengths of CMR in scar imaging.

Keywords: PET/MR; CMR; coronary artery disease; myocarditis; late gadolinium enhancement

Lay summary: This study evaluates how well positron emission tomography (PET) scans that assess the heart muscle’s blood flow can simultaneously detect heart muscle scars, compared to magnetic resonance imaging (MRI). Researchers scanned 100 people with previous cardiac conditions (coronary disease or previous inflammation) with a novel machine combining both PET and MRI in one scanner (PET/MR).

PET scans were good at detecting scars overall, but not as reliable when examining smaller, specific locations. PET was better at detecting scars on the inner heart muscle, typical of coronary disease, and more severe scars. However, it often misses scars typical of previous cardiac inflammation.

Overall, PET scans tended to show less scarring than MRI. Combined imaging of PET and MRI in a novel PET/MR scanner could improve the detection of scars in the future. This study demonstrates the high accuracy of MRI for scar imaging.

Amyloid PET imaging using ¹⁸F-florbetaben predicts mortality in light-chain cardiac amyloidosis

Vergaro G, Aimo A, Genovesi D, et al.

Estimated total amyloid burden from 18F-florbetaben positron emission tomography predicts all-cause mortality in light-chain cardiac amyloidosis

Eur Heart J Cardiovasc Imaging 2025; 26:500-508; https://doi.org/10.1093/ehjci/jeae332

This prospective imaging study evaluated the prognostic utility of ¹⁸F-florbetaben positron emission tomography (PET) imaging in patients with light-chain cardiac amyloidosis (AL). Forty patients with a median age of 69 years and 80% Mayo Stage III underwent PET scans shortly after biopsy-confirmed cardiac AL. Total amyloid burden (TAB) in both ventricles using standardized uptake values was calculated for early and late imaging phases (5-15 min and around 60 min post-injection).

Late-phase left ventricular and right ventricular amyloid burden by PET were independent predictors of all-cause mortality at 18 and 24 months compared to biomarkers such as NT-proBNP and hs-troponin T. Patients with elevated amyloid burden in both ventricles were at the highest risk.

The results suggest that ¹⁸F-florbetaben PET provides prognostic information in cardiac AL amyloidosis. PET imaging may complement existing risk stratification tools and guide individualized clinical decision-making in this high-risk cardiomyopathy population.

Keywords: Amyloid PET; light chain amyloidosis, cardiac amyloidosis, PET/CT, infiltrative cardiomyopathy

Lay summary: In this study, the researchers evaluated the ability of a novel positron emission tomography (PET) scanning technique to detect high-risk patients with amyloid protein infiltration in the heart muscle. A PET scan was able to accurately measure the accumulation of amyloid proteins. A higher burden of amyloid build up was associated with a higher risk of death during follow-up. This new PET scanning method is a promising tool for more individualized non-invasive risk assessment in patients with amyloid heart disease.