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EACVI Research News – October 2023

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, Riccardo Liga, Saloua El Messaoudi, Ana Teresa Timoteo and Arti Ramkisoensing) in collaboration with the EACVI HIT Committee (Giulia Elena Mandoli, Sara Moscatelli and Christina Luong).

Low incidence of cardiac events in high-risk patients undergoing intermediate-to-high-risk non-cardiac surgery using a CMR or a SPECT-MPI stress test

F Fazzari, F Cannata, S Figliozzi et al.

Prognostic role of stress-CMR and SPECT-MPI in patients undergoing intermediate-to-high risk non-cardiac surgery.

Eur Heart J Cardiovasc Imaging 2023; 24;

This study included a total of 1590 patients with a history of coronary artery disease or at least two cardiovascular risk factors, undergoing intermediate-to-high-risk non-cardiac surgery. Of these patients, 669 underwent a myocardial perfusion stress test (287 stress CMR, 382 SPECT-MPI). The rate of 30-day cardiac events was lower in the stress test group vs. the non-stress test group (1.2% vs 3.4%; p 0.006). Adopting a stress test strategy showed a significant reduction of composite endpoint (OR: 0.334, IC 0.155 – 0.766, p 0.009) and acute coronary syndrome (OR: 0.414, IC 0.174-0.984, p 0.046) at multivariable analysis. Stress CMR showed was non-inferior to SPECT in predicting cardiac events and showed a greater accuracy to predict coronary artery revascularisations (AUC for stress CMR: 0.95 with a percentage of myocardial ischemia cut-point of 5.5%). The article suggests that a stress-test strategy is associated with a lower incidence of cardiac events in high-risk patients undergoing intermediate-to-high-risk non-cardiac surgery. The rate of cardiac complications was similarly predicted by stress CMR and SPECT-MPI, although stress CMR was more accurate in predicting coronary artery revascularizations.    


Stress-CMR,  myocardial perfusion

Chronic ischaemic heart disease

risk stratification; non-cardiac surgery

Prognostic value of left ventricular myocardial work indices in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement     

Wu WH, 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; jead157;

Left ventricular myocardial work (LVMW) is a novel echocardiographic-based method to assess left ventricular (LV) function using pressure–strain loops taking into account LV afterload. In this study 281 patients with severe AS planned for elective TAVR procedure, were included. 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. LV GWI was independently associated with all-cause mortality (Hazard ratio per-tertile-increase 0.639; 95%CI 0.463–0.883; P = 0.007), LV GCW, GWW, and GWE were not. 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. This study suggests that 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.  


Pressure-strain loops

Valvular heart disease

Aortic stenosis, TAVR

Postoperative myocardial fibrosis assessment in aortic valvular heart diseases—a cardiovascular magnetic resonance study  

Pires LT, Rosa VEE, Morais TC et al.

Postoperative myocardial fibrosis assessment in aortic valvular heart diseases—a cardiovascular magnetic resonance study

Eur Heart J Cardiovasc Imaging, 2023; 24:851–862;


Left ventricular remodelling occurs during the chronic course of aortic regurgitation (AR) and aortic stenosis (AS), leading to myocardial hypertrophy and fibrosis. Extracellular volume (ECV) and indexed ECV (iECV) are surrogate markers of diffuse myocardial fibrosis. In this study, 99 consecutive patients with severe AR (N=32) or AS (N=67) and indications for surgery were included. Patients underwent pre- and postoperative CMR: ECV and iECV were quantified. After surgery, LV mass index decreased in both groups. The late gadolinium enhancement (LGE) fraction and LGE mass remained stable in both groups. Preoperative iECV and ECV were greater in the AR group (iECV: 30 mL/m2 vs. 22 mL/m2, P=0.001; ECV: 28.4% vs. 27.2%, P=0.048). The iECV decreased after surgery in both groups (AR: 30 to 26.5 mL/m2, AS: 22 to 18.2 mL/m2, P<0.001). Postoperative ECV remained stable in the AR group (preoperative 28.4% vs. postoperative 29.9%; P=0.617) and increased in the AS group (preoperative 27.2% vs. postoperative 28.6%; P=0.033). In conclusion, patients with AR or AS presented reduction in iECV after surgery, unfolding the reversible nature of diffuse myocardial fibrosis. While AR patients developed postoperative iECV regression with stable ECV, suggesting a balanced reduction in both intra- and extracellular myocardial components, AS patients developed postoperative iECV regressione with increased ECV, suggesting a more prominent involution of the myocardial cellular component.       


ECV, iECV, fibrosis, late enhancement

Valvular heart disease

aortic stenosis, aortic regurgitation; aortic valve replacement; fibrosis; remodelling

Automated Echocardiographic Detection of Heart Failure With Preserved Ejection Fraction Using Artificial Intelligence

Akerman A, Porumb M, Scott C et al.      

Automated Echocardiographic Detection of Heart Failure With Preserved Ejection Fraction Using Artificial Intelligence

JACC: Advances 2023; 2: 100452 (ePub);


This retrospective, multisite, and multinational cohort study outlines the development and validation of an Artificial Intelligence (AI) model for detecting Heart Failure with Preserved Ejection Fraction (HFpEF) using echocardiography data. The study employs a dataset from Mayo Clinic and St. George's University Hospitals, involving thousands of patients and video clips of cardiac images. The AI model was trained using Python and TensorFlow, leveraging convolutional neural networks (CNNs) applied to apical four-chamber TTE video clips, and showed high accuracy in differentiating between patients with HFpEF and those without, with an area under the receiver-operating characteristic curve (AUROC) of 0.97 during training. The model's performance was further validated using an independent dataset from Mayo Clinic Health System, showing high sensitivity (87.8%) and specificity (81.9%) in detecting HFpEF diagnosis within 1 year. Overall, the study highlights the model's potential to reduce nondiagnostic outcomes in HFpEF diagnosis compared to existing clinical algorithms and to identify patients at a higher risk of mortality. Moreover, the use of Grad-CAM to visualize regions of importance in echocardiographic images provides a level of interpretability, helping clinicians understand the model's decisions. In summary, this AI model demonstrates promise in detecting and predicting HFpEF, potentially expediting patient access to treatment. While the study is encouraging, further validation and real-world clinical implementation are essential to assess its true clinical utility and benefits.           


Artificial intelligence

heart failure      

Heart failure with preserved ejection fraction

Assessment of extravascular lung water during the recovery phase of exercise stress echocardiography improves the diagnostic accuracy of HFpEF  

Kagami K, Obokata M, Harada T, et al     

Incremental diagnostic value of post-exercise lung congestion in heart failure with preserved ejection fraction

Eur Heart J Cardiovasc Imaging 2023; 24:553-561; https://doi,org/10.1093/ehjci/jead007


In this article, Kagami et al. performed a retrospective study at Gunma University Hospital (Maebashi, Gunma, Japan) between November 2019 and April 2022 to evaluate exertional dyspnea in patients referred for bicycle exercise stress echocardiography. The study focused on diagnosing Heart Failure with preserved Ejection Fraction (HFpEF) using the HFA-PEFF algorithm and assessing exercise-induced extravascular lung water (EVLW) using ultrasound B-lines. The study enrolled 255 consecutive patients, including 134 with HFpEF and 121 controls. The key findings of the study were that exercise EVLW, as indicated by the presence of ultrasound B-lines, was most significant during the recovery period in patients with HFpEF. This finding suggests that assessing EVLW during the recovery phase provides an optimal timeframe to detect pulmonary congestion.     Furthermore, the study found that patients with exercise EVLW had higher LV filling pressures, RV dysfunction, PA-RV uncoupling, and ventilatory inefficiency during exercise, highlighting the clinical significance of exercise-induced EVLW in HFpEF patients. Additionally, the study demonstrated that incorporating the assessment of exercise EVLW into diagnostic evaluation improved the accuracy of identifying HFpEF when combined with established diagnostic tools like the H2FPEF score and LA reservoir strain. While the study provides valuable insights into the dynamic changes in lung water during exercise in HFpEF patients, it also acknowledges certain limitations, such as selection bias and the need for further research to confirm the diagnostic value of EVLW. In summary, this research highlights the potential of exercise-induced EVLW assessments, particularly during the recovery period, in diagnosing HFpEF and offers a promising approach to enhance the accuracy of HFpEF diagnosis.           


Stress Echo, Lung ultrasound     

heart failure

pulmonary congestion

Novel accelerated sequences allow cardiovascular magnetic resonance to estimate mean pulmonary artery pressure non-invasively in less than 2 minutes

Abdula G, Ramos JG, Marlevi D, et al.

Non-invasive estimation of mean pulmonary artery pressure by cardiovascular magnetic resonance in under 2 min scan time       

Eur Heart J - Imaging Methods and Practice 2023; 1:qyad014;


Non-invasive estimation of mean pulmonary artery pressure (mPAP) can be assessed by cardiovascular magnetic resonance (CMR) using a four-dimensional (4D) flow sequence, with the major limitation of relatively long scan times. In this paper, the Authors investigated the accuracy of a novel compressed sensing (CS) accelerated sequence in 51 patients referred to CMR, by acquiring multiple 2D slice phase-contrast three-directional velocity-encoded images covering the pulmonary artery. Prototype software was used for the blinded analysis of pulmonary artery (PA) vortex duration to estimate mPAP: the principle is that the greater the number of time frames in which a vortex can be detected in flow images, the higher the estimated mean pulmonary artery pressure.

The novel CS-accelerated sequence showed comparable results to the non-CS-accelerated acquisition: the mean bias for estimating mPAP between the two methods was 0.1 ± 1.9 mmHg and the intraclass correlation coefficient was 0.97 (95% confidence interval 0.94–0.98). Effective scan time was reduced by nearly 80% with the CS-accelerated acquisition compared to the non-CS acquisition (2 min vs. 9 min, respectively).

CS-accelerated phase-contrast CMR could represent a tool for estimating intracardiac pressures, without any substantial addition in protocol time. In a near future, this technique might substantially increase the versatility of CMR across several different cardiac diseases.


4D flow; pulmonary pressure; parallel imaging; accelerated imaging        

pulmonary hypertension            

heart failure; valve diseases; pulmonary pressure

Low-dose computed tomography allows detection of fatty liver disease, which is associated with the risk for myocardial ischaemia

Hokkanen A, Hämäläinen H, Laitinen TM, et al.  

Decreased liver-to-spleen ratio in low-dose computed tomography as a biomarker of fatty liver disease reflects risk for myocardial ischaemia       

Eur Heart J - Imaging Methods and Practice 2023; 1:qyad016;


Low-dose computed tomography is often used with other imaging modalities, especially in nuclear medicine. In this article, the Authors evaluated the presence and clinical correlates of fatty liver disease (FLD) in 742 patients undergoing low-dose non-contrast computed tomography (LDCT) as part of a myocardial perfusion imaging study. A liver-to-spleen ratio (in Hounsfield units) of <1 was defined as FLD. Patients with FLD were younger (63 vs. 68 years), had a higher body mass index (34.6 vs. 29.0 kg/m2) and a higher summed difference score (2.65 vs. 1.63), P < 0.001 for all. Independently of several possible confounding factors including traditional risk factors, patients with FLD had a 1.70-fold risk of ischaemia, defined as a summed difference score (SDS) ≥3 (95% confidence interval 1.11–2.58, P = 0.014).

This study shows that fatty liver disease can be easily identified as a free by-product of low-dose computed tomography images acquired as part of other diagnostic imaging and that it may help to identify patients who are at higher risk of heart disease.


low-dose CT; fatty liver disease  

chronic ischaemic heart disease

myocardial ischaemia; fatty liver disease

Deep learning in echocardiography to reduce left ventricular foreshortening and variability

Sabo S, Pettersen HN, Smistad E, et al.   

Real-time guiding by deep learning during echocardiography to reduce left ventricular foreshortening and measurement variability 

Eur Heart J - Imaging Methods and Practice 2023; 1: qyad012;


Apical foreshortening is an important limitation in left ventricular function assessment, particularly in less experienced operators, due to underestimation of left ventricular (LV) volumes and an overestimation of LV ejection fraction and global longitudinal strain.  A total of 88 patients in sinus rhythm underwent transthoracic echocardiography, performed by sonographers in a first assessment and repeated in a second assessment, guided by real-time deep learning (DL) to reduce foreshortening. A third echocardiogram was performed by a Cardiologist, that also measured LV length in all recordings, that was used as reference. Both sonographer groups significantly foreshortened the LV in step 1, and this was reduced in step 2. Sonographers using DL guiding did not foreshorten more than cardiologists. Therefore, real-time guiding reduced foreshortening among experienced operators and has the potential to improve image standardization. However, the effect on inter-operator variability was minimal among experienced users. Nevertheless, real-time guiding may improve test–retest variability among less experienced users.


Artificial intelligence; foreshortening

Heart failure

Heart failure; Valvular heart disease; Cardiomyopathies; chamber quantification; volume quantification

Predictors of aortic stenosis progression

Seo JH, Kim KE, Chun KJ, et al.   

How can progression be predicted in patients with mild to moderate aortic valve stenosis?

Eur Heart J Cardiovasc Imaging 2023; 24: 1146-1153;


The identification of prognostic markers of aortic valve stenosis (AS) progression is of extremely importance. Therefore, the authors studied 481 patients with mild to moderate AS and the pressure increase per time unit (dP/dt) in aortic valve jet velocity by transthoracic echocardiography was assessed. Patients were followed-up for a median of 2.7 years and 3% progressed from mild to severe AS and 40% from moderate to severe AS. This parameter showed good ability to predict risk of progression to severe AS (area under the curve = 0.868), with a cut-off value of 600 mmHg/s. Moreover, in multivariable logistic regression, this parameter (OR 1.52/100 mmHg/s higher dP/dt; 95% CI, 1.10–2.05; P = 0.012) and initial AoV calcium score were associated with progression to severe AS. In conclusion, AoV Doppler-derived dP/dt above 600 mmHg/s was associated with risk of AS progression to the severe stage in patients with mild to moderate AS. This may be useful in individualized surveillance strategies for AS progression.             


Pressure increase; dP/dt

Valvular heart disease

Aortic stenosis

Left ventricular end-systolic volume predicts post-operative left ventricular dysfunction in degenerative mitral regurgitation

Althunayyan AM, Alborikan S, Badiani S, et al.    

Determinants of post-operative left ventricular dysfunction in degenerative mitral regurgitation.      

Eur Heart J Cardiovasc Imaging 2023; 24: 1252–1257;   


Current thresholds for surgery in patients with chronic degenerative mitral regurgitation are based in left ventricular (LV) diameters and ejection fraction. However, this condition is characterized by volume overload that will determine LV enlargement and dysfunction. This study aim was to assess the impact of LV volumes and other new markers of LV performance on outcomes of surgery in mitral valve prolapse. In this prospective and observational study, 87 patients with mitral valve prolapse undergoing mitral valve surgery were assessed by echocardiography pre- and post-operatively. LV impairment was defined as LV ejection fraction < 50% one year after surgery, and it occurred in 13% of patients. Those patients showed larger indexed LV end-systolic diameters, indexed LV end-systolic volumes (LVESVi), lower LV ejection fraction, and more abnormal GLS. In multivariate analysis, LVESVi [odds ratio 1.11 (95% CI 1.01–1.23), P = 0.039] and GLS [odds ratio 1.46 (95% CI 1.00–2.14), P = 0.054] were the only independent predictors of post-operative LV dysfunction. The optimal cut-off of LVESVi was 36.3 mL/m2 with a sensitivity of 82% and specificity of 78% for detection of post-operative LV impairment. This can be a useful marker of post-operative LV dysfunction.


LV volumes; LV strain; remodelling

Valvular heart disease

Mitral regurgitation; mitral prolapse; post-surgery remodelling

Interaction between right ventricular perfusion, hemodynamic load, and prognosis in patients with cardiac amyloidosis 

Harms HJ, Clemmensen T, Rosengren S, et al.     

Association of Right Ventricular Myocardial Blood Flow With Pulmonary Pressures and Outcome in Cardiac Amyloidosis   

J Am Coll Cardiol Img 2023; 16: 1193–1204;


The study evaluated the functional and prognostic role of right ventricular (RV) myocardial blood flow (MBF) abnormalities in patients with cardiac amyloidosis (CA). Cardiac PET with 11C-acetate and/or 15O-water was performed in 52 patients with CA and in 9 controls. MBF of the right ventricle (MBFRV) and the ratio of MBFRV to MBF of the left ventricle (MBFRV/LV) for the 2 traces were significantly correlated. Measures of MBFRV was directly correlated with RV systolic pressures, as well as N-terminal pro–B-type natriuretic peptide levels, NYHA functional class, RV pressures, and RV systolic function. Twenty-six cardiac events (death or acute heart failure) occurred during follow-up (median 44 months). MBFRV/LV higher than 56% was associated with a diagnosis of pulmonary hypertension (AUC: 0.96; P < 0.0001) and predicted aa worse outcome (HR: 9.0, 95% CI: 4.2-14.5, P < 0.0001). The Authors demonstrated the feasibility of measuring MBFRV using PET. Imbalance between RV and LV myocardial perfusion is associated with increased RV load and adverse events in cardiac amyloidosis.     


PET, perfusion  


Right ventricular perfusion

Normal values of transient ischemic dilation (TID) in patients imaged with a dedicated cardiac CZT camera

Sim EWJ and Yew MS

Transient ischaemic dilation ratio thresholds in patients with zero coronary calcium score undergoing exercise or dipyridamole stress SPECT myocardial perfusion imaging using a cadmium-zinc-telluride camera

Eur Heart J - Imaging Methods and Practice 2023; 1, 1–7;


Transient ischaemic dilation (TID) during myocardial perfusion imaging (MPI) has been proposed as a marker of extensive and significant coronary artery disease (CAD). However, the correct cut-off for a normal TID ratio (TIDr) is still debated, particularly in the setting of novel dedicated cardiac CZT cameras. The Authors studied 232 patients with zero CAC and normal MPI undergoing either exercise of dipyridamole stress CZT imaging using either a 1- or 2- day protocol. The TIDr cut-offs calculated using the mean + 2 standard deviations were 1.29 and 1.24 for the 1- and 2-day protocol groups, respectively. In patients undergoing a 2-day protocol, dipyridamole stress resulted in significantly higher mean TIDr when compared to exercise stress (1.07 ± 0.13 vs. 1.01 ± 0.12, P = 0.035). This study was the first to derive TIDr thresholds using a normal population defined by zero CAC and normal MPI. TIDr was found to vary depending on stress modality, protocol as well as the software used.     


SPECT; CZT        

chronic ischaemic heart disease

diagnosis; transient ischemic dilatation

Haemodynamic force analysis  of CMR cine images allows estimation of  intraventricular pressure gradients, which are associated with prognosis in dilated cardiomyopathy        

Vos JL, Raafs AG,  Henkens MTHM et al.

CMR-derived left ventricular intraventricular pressure gradients identify different patterns associated with prognosis in dilated cardiomyopathy   

Eur Heart J - Cardiovascular Imaging 2023; 24: 1231–1240;


Haemodynamic force analysis is a novel method to calculate the global intraventricular pressure gradient (IVPG) between apex and base of the LV from cine cardiovascular magnetic resonance (CMR) postprocessing: blood velocity over the endocardial boundary can be derived from the myocardial movement using feature tracking strain, while blood velocity across the valves can be calculated from the volumetric changes of the LV and the valve area. In this study, LV-IVPGs were measured in 447 DCM patients from the Maastricht Cardiomyopathy registry. Intriguingly, 38% (168 patients) showed a temporary LV-IVPG reversal during the systolic–diastolic transition. This reversal affected the blood flow direction in 14% of cases, and these reversals were linked to worse patient outcomes.

For the subset of DCM patients who did not exhibit this pressure reversal, other parameters came into play. Notably, decreased systolic ejection force, E-wave decelerative force (which marks the end of passive LV filling), and overall LV-IVPG values were highlighted as potent predictors of patient outcomes. These findings were consistent even when considering other established predictors like age, sex, New York Heart Association class ≥3, LV ejection fraction, late gadolinium enhancement, LV-longitudinal strain, left atrium (LA) volume-index, and LA-conduit strain. In summary, CMR post-processing with LV-IVPG analysis can provide valuable insights into DCM patient outcomes by observing LV blood flow patterns, especially pressure reversals.


Feature tracking; strain; intraventricular pressure gradient


dilated cardiomyopathy

Apical papillary muscle displacement is a precursor of apical hypertrophic cardiomyopathy            

Filomena D, Vandenberk B, Dresselaers T, et al.

Apical papillary muscle displacement is a prevalent feature and a phenotypic precursor of apical hypertrophic cardiomyopathy       

Eur Heart J - Cardiovascular Imaging 2023; 24: 1009-1016;


The study aimed to examine the occurrence and frequency of Papillary muscle (PM) displacement across various hypertrophic cardiomyopathy (HCM) phenotypes. Using cardiovascular magnetic resonance (CMR), 156 patients were analyzed and categorized into three groups based on their HCM phenotype: septal hypertrophy (Sep-HCM), mixed hypertrophy (Mixed-HCM), and apical hypertrophy (Ap-HCM). Apical PM displacement occurred in 55% of patients and was most prevalent in the Ap-HCM group, followed by Mixed-HCM and Sep-HCM. Significant PM displacement differences emerged when comparing a control group of 55 healthy people to Ap-HCM and Mixed-HCM patients, but not with Sep-HCM patients. T-wave inversion was also most common in Ap-HCM patients. Remarkably, PM displacement was noted even before the manifestation of hypertrophy in Ap-HCM patients, pointing to a potential mechanical and pathogenetic correlation between the displacement and Ap-HCM. The findings highlight that monitoring PM displacement could be pivotal in early Ap-HCM diagnosis.


Papillary muscles



Global longitudinal strain from 3D-echocardiography correlates with heart failure severity and prognosis in Fabry disease 

Marek J, Chocholová B, Rob D et al.        

Three-dimensional echocardiographic left ventricular strain analysis in Fabry disease: correlation with heart failure severity, myocardial scar, and impact on long-term prognosis 

Eur Heart J - Cardiovascular Imaging 2023; jead121;


In this article the Authors assessed the echocardiographic 3D left ventricular (LV) strain of patients with FD in relation to heart failure severity and long-term prognosis. 3D echocardiography was feasible in 75/99 patients: 3D LV global longitudinal strain (GLS) showed a stronger correlation than 3D LV global circumferential strain (GCS) or 3D LVEF. During a median 3-year follow-up, 3D LV-GLS was associated with long-term prognosis, while 3D LV-GCS and 3D LVEF were not. In summary, 3D LV-GLS is associated with both heart failure severity measured by natriuretic peptide levels and long-term prognosis and can be used for a comprehensive mechanical assessment of the LV in patients with FD.      


3D echocardiography    


hypertrophic cardiomyopathy, Fabry disease

Prevalence and significance of relative apical sparing in aortic stenosis (an echo and CMR study)

Abecasis J, Lopes P, Santos RR, et al.       

Prevalence and significance of relative apical sparing in aortic stenosis: insights from an echo and cardiovascular magnetic resonance study of patients referred for surgical aortic valve replacement.   

Eur Heart J Cardiovasc Imaging 2023; 24: 1033–1042;


Relative apical sparing pattern (RAPS), defined by an apical longitudinal strain (LS) > average (basal + mid) LS at echocardiography, is sometimes described in patients with severe symptomatic aortic stenosis (AS). However, its prevalence, clinical significance, and interpretation is equivocal. This is a prospective study of 150 patients (mean age 73 years, 51% women), with severe symptomatic AS referred to surgical aortic valve replacement. Patients underwent a transthoracic echocardiogram and cardiac magnetic resonance. Surgery was performed in 119 (79.3%) patients. A septal myocardial biopsy was performed to exclude amyloid by histology. LV remodeling and tissue characterization parameters were compared in patients with and without RASP. Deformation pattern was re-assessed at 3–6 months after AVR. RASP was present in 15.3% of the patients. There was no suspicion of amyloid at pre-operative CMR and none of the patients had amyloid deposition at histopathology. Patients with RASP had significantly higher pre-operative LV mass and increased septal wall thickness, lower LV ejection fraction, and higher absolute late gadolinium enhancement (LGE) mass at CMR. Follow-up evaluation after AVR revealed RASP disappearance in all except two of the patients. Therefore, RASP is not specific of cardiac amyloidosis and it is frequent in severe symptomatic AS without amyloidosis, reflecting advanced LV disease, being mostly reversible after surgery.    


Echo; CMR        

Valvular heart disease

Aortic stenosis; Strain; Apical sparing

Regional impaired myocardial mechanical function in heart failure with preserved ejection fraction

Biering-Sørensen T, Cikes M, Lassen MCH, et al. 

Regional contributions to impaired myocardial mechanical function in heart failure with preserved ejection fraction. 

Eur Heart J Cardiovasc Imaging 2023; 24: 1110–1119;


Hypertensive heart disease (HHD) is recognized as a key clinical precursor to heart failure with preserved ejection fraction (HFPEF). The Authors assessed regional myocardial deformation in a cohort of 327 adults with preserved left ventricular (LV) ejection fraction (≥45%), 129 with HFPEF, 158 with HHD and no heart failure, and 40 normotensive controls. They compared regional measures of basal, mid-ventricular, and apical longitudinal strains. In models adjusting for clinical covariates, basal and mid-ventricular LV myocardial deformation was more impaired in HHD than in controls, whereas apical deformation was more impaired in HFPEF than in HHD. In multivariable-adjusted analyses, only apical strain remained independently associated with HFPEF vs. HHD status [odds ratio 1.18 (1.02–1.37), P = 0.030 per 1% decrease in apical strain]. Apical longitudinal strain optimally differentiated HFPEF from HHD (area under the receiver operating curve: apical longitudinal strain = 0.67; mid-ventricular longitudinal strain = 0.59; basal longitudinal strain = 0.60). Therefore, while apical mechanical function is preserved in HHD, it was impaired in HFPEF and may contribute to the transition from an asymptomatic heart disease to a symptomatic heart disease.  


Longitudinal strain

Heart failure

Heart Failure with preserved Ejection Fraction; hypertensive heart disease

Patients with coronary calcium scores >300 are at an equivalent cardiovascular risk as those treated for established atherosclerotic cardiovascular disease

Budoff MJ, Kinninger A, Gransar H, et al.

When Does a Calcium Score Equate to Secondary Prevention? Insights From the Multinational CONFIRM Registry      

J Am Coll Cardiol Img 2023; 16: 1181–1189;


Elevated coronary artery calcium (CAC) is associated with increased cardiovascular risk. However, the value of CAC score that identifies patients still in primary prevention that should be treated as aggressively for cardiovascular risk factors as those who have already suffered atherosclerotic cardiovascular disease (ASCVD) event is unknown. In this cohort study of 4949 patients enrolled in the CONFIRM registry the Authors compared major adverse cardiovascular event (MACE) rates in persons without a history of myocardial infarction (MI) or revascularization (as categorized on CAC scores) to event rates in those with established ASCVD. Incident MACEs increased with higher CAC scores, with the highest rates observed with CAC score >300 and in those with prior ASCVD. All-cause mortality, MACEs, MACE + late revascularization, and myocardial infarction event rates were not statistically significantly different in those with CAC >300 compared with established ASCVD (all P > 0.05). Persons with a CAC score <300 had substantially lower event rates. The study will help to identify the level of CAC score that is associated with a degree of risk equivalent patients in secondary prevention.      


CCTA; Calcium Score

chronic ischaemic heart disease

Primary prevention; prognosis

Phenotyping heart failure with echocardiography: a review of established and novel parameters  

Smiseth OA, Donal E, Boe E et al.            

Phenotyping heart failure by echocardiography: imaging of ventricular function and haemodynamics at rest and exercise            

Eur Heart J - Cardiovascular Imaging 2023; 24: 1329–1342;


In this review, the Authors discuss additional echocardiographic modalities to enhance the diagnostic process of both heart failure with reduced ejection fraction as well as heart failure with preserved ejection fraction. In particular, speckle tracking strain is complementary to determination of the left ventricular ejection fraction, as it is more sensitive to diagnose mild systolic dysfunction. Segmental strain patterns may be used to identify specific cardiomyopathies. Echocardiography may also detect an elevated LV filling pressure, and a stress test may be used to identify abnormal elevation of filling pressure during exercise in patients with normal LV filling pressure at rest. The novel parameter LV work index, which incorporates afterload, is a promising tool for quantification of LV contractile function and efficiency. Another novel modality is shear wave imaging, which is a promising tool for assessing ventricular stiffness. This article also discusses the possibility of creating digital twins of systolic and diastolic performance, which are computational representations of patient-specific left ventricular performance, offering new opportunities for better management of heart failure. In conclusion, echocardiographic assessment of cardiac function should include not only LV strain as a supplementary method to LVEF, but also several other novel functional parameters for a finer evaluation of systolic and diastolic function in heart failure patients.


Systolic function; diastolic function; strain; LV work index; shear wave imaging

Heart failure     


Association between non-invasively determined pulmonary artery pulsatility index with mortality in patients with moderate/severe tricuspid regurgitation   

Kane CJ, Lara-Breitinger KM, Alabdaljabar MS, et al.

Pulmonary artery pulsatility index in patients with tricuspid valve regurgitation: a simple non-invasive tool for risk stratification      

Eur Heart J - Cardiovascular Imaging 2023; 24: 1210–1221;


The Authors of this study investigated whether there is an association of pulmonary artery pulsatility index (PAPi, the ratio of PA pulse pressure to right atrial (RA) pressure) with mortality in patients with moderate or severe tricuspid regurgitation. The noninvasive measurement of PAPi by calculation of measures routinely acquired on echocardiograms was also investigated. It was concluded that when the Doppler signals are of adequate quality and an established standard approach to estimate RA pressure is used, the non invasively determined PAPi is reliable. The Authors also demonstrated that in moderate or severe TR, PAPi and the presence of pulmonary hypertension are independently associated with markers of right heart failure and mortality.


Pulsatility index

Valvular heart disease

Tricuspid regurgitation

Functional mitral Regurgitation fraction and Myocardial Scar Quantification by Cardiac Magnetic Resonance predict prognosis in patients with ischaemic or non-ischaemic left ventricular dysfunction   

Wang TKM, Kocyigit D, Choi H, et al.       

Prognostic Power of Quantitative Assessment of Functional Mitral Regurgitation and Myocardial Scar Quantification by Cardiac Magnetic Resonance         

Circ Cardiovasc Imaging 2023; 16:e015134;


The Authors investigated whether quantitative assessment of functional mitral regurgitation with cardiac magnetic resonance can provide incremental risk stratification for patients with ischemic (ICM) or non-ischaemic (NICM) left ventricular dysfunction, its thresholds and its interactions with late gadoliniun enhancement (LGE). Among 1414 patients with left ventricular ejection fraction <50%, the primary endpoint (all-cause death, heart transplant, or left ventricular assist device implantation) occurred in 510, corresponding to 395/782 (50.5%) in ICM and 114/632 (18.0%) in NICM. Each 5% increase of mitral regurgitation was independently associated with the primary end point: based on the prediction of the primary outcome, optimal mitral regurgitation-fraction threshold were ≥20% for moderate and ≥35%  for severe regurgitation in both ICM and NICM. Similarly, optimal LGE thresholds were ≥5% in ICM and ≥2% in NICM. Mitral regurgitation-fraction × LGE resulted a significant interaction for the primary end point in ICM (P=0.006), but not in NICM (P=0.971).         


phase contrast, LGE       

valvular heart disease

mitral regurgitation

Cardiac magnetic resonance refines diagnosis and prognosis in patients with a working diagnosis of MINOCA    

Konst RE, Parker M, Bhatti L, et al.

Prognostic Value of Cardiac Magnetic Resonance Imaging in Patients With a Working Diagnosis of MINOCA—An Outcome Study With up to 10 Years of Follow-Up          

Circ Cardiovasc Imaging 2023; 16:e014454;


This study described the results from a prospective registry of consecutive patients with a working diagnosis of MINOCA referred for CMR. Among 252 patients, CMR detected acute myocardial infarction (true MINOCA) in 63 (25%), myocarditis in 33 (13%), nonischaemic cardiomyopathy in 111 (44%), normal findings in 37 (15%), and other diagnoses in 8 (3%). During up to 10 years of follow-up, major adverse cardiovascular events occurred in 84 patients (33%): the unadjusted cumulative 10-year rate was 47% in acute myocardial infarction, 24% in myocarditis, 50% in nonischaemic cardiomyopathy, and 3.5% in patients with a normal CMR (Log-rank P<0.001). The CMR diagnosis provided incremental prognostic value over clinical factors including age, gender, coronary artery disease risk factors, presentation with ST-elevation, and peak troponin.


Diagnosis; prognosis

acute ischaemic heart disease (including MINOCAS)        

MINOCA, Takotsubo, myocarditis

Quantitative flow ratio (QFR) shows a higher diagnostic performance than myocardial perfusion imaging in patients with prior coronary artery disease

van Diemen PA, de Winter RW, Schumacher SP, et al.      

The Diagnostic Performance of QFR and Perfusion Imaging in Patients with Prior Coronary Artery Disease. Eur Heart J Cardiovasc Imaging 2023; jead197;


In patients with previous CAD and new stable anginal symptoms stress imaging or direct invasive coronary angiography (ICA), complemented with measurement of fractional flow reserve (FFR) by a pressure wire approach, is recommended for guiding invasive interventions. Nevertheless, implementation of FFR measurement is not routine clinical practice, due to additional costs and risks. In the present sub-analysis of the PACIFIC-2 trial, performed in 189 patients with prior myocardial infarction and/or PCI, the Authors demonstrate that measurement of quantitative flow ratio (QFR), using fast fluid dynamics and a 3D-reconstruction of the coronary artery derived from ICA, correlated better with FFR than non invasive stress myocardial perfusion imaging including SPECT, PET, and CMR. Despite this approach was successful in only 68% of vessels, this exploratory analysis seems very promising in particular considering that in real world practice a direct invasive approach is frequently chosen but FFR is rarely measured.             


Invasive Coronay Angiography, quantitative flow ratio (QFR)        

Chronic ischaemic heart disease

Functionally significant CAD, diagnostic accuracy

Right ventricular myocardial work with speckle tracking echocardiography predicts right heart failure and mortality after left ventricular assist device implant


Landra F, Sciaccaluga C, Pastore MC et al

Right Ventricular Myocardial Work for the Prediction of Early Right Heart Failure and Long-term Mortality After Left Ventricular Assist Device Implant

Eur Heart J Cardiovasc Imaging 2023; jead193;


Myocardial work (MW) is a non-invasive Speckle Tracking Echocardiography-derived method to estimate pressure–volume loops and can be applied to evaluate the performance of right ventricular myocardial work and predict right heart failure (RHF) after left ventricular assist device (LVAD) implant. In this retrospective study on 23 patients undergoing LVAD implant the Authors found that a lower right ventricular global work efficiency (RVGWE) was associated with the occurrence of early (<30 days) RHF. Among all MW indices, RVGWE showed the best accuracy in predicting early RHF. During a median one year follow-up, death occurred in 4 of 14 patients (28.6%) in the RVGWE >77% group and in 6 of 9 patients (66.7%) in the RVGWE < 77% group, suggesting a prognostic value of RVGWE also in terms of long-term mortality.    


myocardial work; speckle tracking; echocardiography     

heart failure      

end-stage heart failure, LVAD

Apical-to-basal longitudinal strain ratio predicts the occurrence of conduction disorders after surgical or transcatheter aortic valve replacement     

Laenens D, Stassen J, Galloo X et al.

Association between left ventricular apical-to-basal strain ratio and conduction disorders after aortic valve replacement        

J Am Soc Echocardiogr 2023; S0894-7317(23)00481-9;


Conduction disorders after aortic valve replacement (AVR) are not so rare, and very few predictors have been identified so far. In this study, the Authors investigated whether left ventricular apical-to-basal longitudinal strain differences, as a marker of basal interstitial fibrosis and/or amyloidosis, are associated with the occurrence of conduction disorders after AVR. The apical-to-basal strain ratio was calculated by dividing the average strain of the basal segments by the average strain of the apical segments. In 274 patients with severe aortic stenosis, an abnormal (>1.9) apical-to-basal strain ratio was the only independent factor associated with the occurrence of complete bundle branch block or permanent pacemaker implantation during a median follow-up of 12.2 months  after surgical (n=126 [46%]) or transcatheter (n=148 [54%]) AVR. Subgroup analysis confirmed the independent association of an abnormal apical-to-basal strain ratio with conduction disorders after transcatheter AVR. In summary, an impaired apical-to-basal strain ratio is independently associated with conduction disorders after AVR and could guide risk stratification in patients potentially at risk for pacemaker implantation.


speckle tracking

valvular heart disease

aortic valve replacement; conduction disorders

Left ventricular early diastolic slopes from strain-volume loops is significantly associated with adverse events in HEpEF patients  


Kerstens TP, Weerts J, van Dijk APJ et al. 

Association of left ventricular strain-volume loop characteristics with adverse events in patients with heart failure with preserved ejection fraction             

Eur Heart J Cardiovasc Imaging 2023; 24:1168-1176;


Heart failure with preserved ejection fraction (HFpEF) is characterized by an impaired diastolic function. Left ventricular (LV) strain-volume loops (SVL) represent the relation between strain and volume during the cardiac cycle and provide insight into systolic and diastolic function characteristics. In this study, the Authors investigated the association between SVL parameters and adverse events (all-cause mortality and heart failure hospitalizations) in 235 HFpEF patients. During a 2.9 year follow-up, 73 patients (31%) experienced an event. Early diastolic slope, representing the relationship between changes in LV volume and strain during early diastole, but not other SVL-parameters, was significantly associated with adverse events after adjusting for age, sex, and NYHA class.       


myocardial work; speckle tracking

heart failure      

HFpEF; prognosis

Women present a 12-year delay in the onset of coronary atherosclerosis than men, but women within the highest atherosclerotic burden group are at significantly higher risk for cardiovascular events      

van Rosendael SE, Bax AM, Lin FY, et al.

Sex and age-specific interactions of coronary atherosclerotic plaque onset and prognosis from coronary computed tomography       

Eur Heart J Cardiovascular Imaging 2023; 24: 1180–1189;


The global coronary atherosclerotic plaque burden measured by coronary computed tomography angiography (CCTA) is an established prognostic indicator. This study examines the differences in age onset and prognostic significance of atherosclerotic plaque burden between sexes. From a large multi-center CCTA registry the Leiden CCTA score (an integrated measurement that incorporates stenosis severity, plaque location, extent, and composition) was calculated in 24,950 patients (11,678 women and 13,272 men) followed for 3.7 years. Major adverse cardiovascular events included death and myocardial infarction. The study demonstrated that Women develop coronary atherosclerosis approximately 12 years later than men and that the Leiden CCTA risk score is independently associated with MACE in both sexes. In particular, while in pre-menopausal women the risk score was equally predictive and comparable with men, post-menopausal women within the highest atherosclerotic burden group were at significantly higher risk for MACE than their male counterparts, underscoring the need for intense medical treatment in these subjects.  


CT Angiography, CAD Risk score 

chronic ischaemic heart disease

CAD prognosis, CT measured total plaque burden

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.