Echocardiography
Among patients with invasively proven HFpEF, the 2025 ASE algorithm frequently assigns normal or low diastolic grades, and the recommended stress criteria detect only a minority of cases
Harada T, Sorimachi H, Obokata M, et al.
Echocardiographic Diastolic Function Grading in HFpEF: Testing the Updated 2025 ASE Criteria
J Am Coll Cardiol 2026; 87:1261-1275; https://doi.org/10.1016/j.jacc.2025.11.024
This study aimed to evaluate the new algorithm for diastolic disfunction from the latest 2025 American Society of Echocardiography (ASE) recommendation. The study included 756 patients with heart failure with preserved ejection fraction (HFpEF) who underwent invasive exercise testing and standard resting and stress exercise echocardiography. The study evaluated the false-negative rate of ASE algorithm for diastolic function among invasively confirmed HFpEF. Additionally, it evaluated how the grading of diastolic function varied with congestion status. Results indicated that up to 67.6% of patients who had invasively confirmed HFpEF had normal diastolic function or grade 1 diastolic disfunction. In patients with grade 1 diastolic dysfunction who underwent stress exercise, only 11 of 116 (9.5%) met the ASE-recommended stress criteria (E/e′ ≥14 or medial E/e′ ≥15 and an exercise TRV ≥3.2 m/s), resulting in a 90.5% false-negative rate. In hospitalised decompensated HFpEF patients normal or grade 1 diastolic disfunction was found in 22 of 88 (25%) patients and increased to 45 (51%) after recompensation, with a meaningful rise in normal/grade 1 diastolic dysfunction (45 of 88 (51.1%) patients). The study concludes that among patients with invasively proven HFpEF, the latest 2025 diastolic algorithm has inadequate sensitivity, as it frequently assigns normal or grade 1 diastolic dysfunction, and stress criteria detect only a minority of patients with HFpEF.
Keywords: echocardiography, diastolic function, stress echocardiography, HFpEF, guidelines
Lay summary: A recent study looked at how well a new 2025 echocardiographic recommendation can detect diastolic dysfunction, a problem where the heart becomes stiff and does not relax properly. The study included 756 patients with a heart failure with preserved ejection fraction (HFpEF), confirmed by invasive testing. It found that the new method often missed the diagnosis. More than two thirds (67.6%) of patients with proven HFpEF were labelled as having normal or only mild diastolic dysfunction. During exercise testing, the method was even less accurate—over 90% of patients who truly had HFpEF were not detected by the recommended stress criteria. This means that many people with HFpEF may be overlooked if doctors rely solely on the current echocardiographic recommendation, and that they need to consider other information when evaluating patients suspected of having HFpEF.
Noninvasive assessment of impaired left ventricular relaxation by reduced early diastolic mitral annular velocity shows a modest association with invasively-assessed left ventricular relaxation time
Ohte N, Smiseth OA, Kikuchi S, et al.
Predictive value of early diastolic mitral annular velocity and body mass index as markers of left ventricular relaxation: Validation against invasive time constant of relaxation.
Eur Heart J Cardiovasc Imaging 2026: jeag067; http://doi.org/10.1093/ehjci/jeag067
This study aimed to assess the association between invasively assessed left ventricular (LV) relaxation time constant tau (τ) and echocardiographic tissue Doppler parameter of early diastolic mitral annular velocity (e′). Additionally, it assessed the association of τ and body mass index, heart rate, blood pressure, and age. The study included 491 consecutive patients who underwent diagnostic cardiac catheterisation for the evaluation of coronary artery disease and comprehensive invasive LV functional evaluation with analysis of LV pressure waves obtained with a catheter-tipped micromanometer. All patients also had transthoracic echocardiography for assessing tissue Dopler parameters. Results indicated that there is only weak association between mean e′ and τ (r = −0.27, P < 0.001). Multivariable analysis revealed that age did not significantly influence τ, whereas it was a strong determinant of mean e′ (β=−0.467, P < 0.001). Body mass index and LV geometry were an independent predictor for both τ and mean e′.
The study concluded that the determinants of invasive time constant τ and mean e′ are only partially overlapping and have distinct physiological bases. Additionally, the study suggests that increased body mass index is associated with impaired LV relaxation.
Keywords: echocardiography, diastolic function, left ventricle, relaxation
Lay summary: This study tested how invasive measurement of relaxation of left ventricle (tau) relate to echocardiographic measurement of relaxation (e′) and to other factors such as body weight, heart rate, blood pressure and age. The study included 491 patients who had cardiac catheterisation with invasive measurement of tau and transthoracic echocardiography. The study showed that these two measures (tau and e′) did not strongly relate to each other. Body weight and the shape of the left ventricle were linked to both measures (tau and e′). This means that invasive measurement (tau) and echocardiographic measurement (e′) do not always give the same information about left ventricular relaxation and that a higher body weight is linked with poorer heart relaxation.
Removal of immunoglobulin G antibodies by immunoadsorption is safe and well tolerated in dilated cardiomyopathy, but did not improve LVEF or HF symptoms after 6 months
Felix SB, Böhm M, Braun-Dullaeus RC, et al.
Immunoadsorption in dilated cardiomyopathy: the IASO-DCM trial.
Eur Heart J 2026: ehaf1055; https://doi.org/10.1093/eurheartj/ehaf1055
In dilated cardiomyopathy (DCM) genetic factors, inflammation, and cardiac-specific antibodies may drive disease progression. If relevant, removing cardiac antibodies may improve patient outcomes. This was a multicentre, double-blind, sham-controlled, randomized phase 2 study. This trial evaluated the effects of immunoadsorption (IA) and subsequent IgG substitution (IA/IgG) on LVEF after 6 months using contrast-enhanced echocardiography in patients with DCM. Key inclusion criteria were DCM, LVEF < 40%, New York Heart Association (NYHA) classes II–IV, HF symptoms for 6 months to 7 years, and guideline-directed HF treatment for at least 6 months. Between 2008 and 2018, 576 outpatients were screened, with 171 enrolled and assigned to either immunoadsorption with IgG substitution (IA/IgG, n=83) or control (n=88). After 6 months, LVEF increased from 29 ± 1 to 34 ± 1% in the IA/ IgG group and from 29 ± 1 to 32 ± 1% in the control group. The increase in LVEF did not differ significantly (P = .08) between the IA/IgG group and the control group. The neutral effect of IA/IgG on LVEF was consistent across all subgroups except one. A post hoc analysis revealed a significant interaction in patients receiving sacubitril/valsartan, a medication newly introduced in the guidelines during the study period (P = .003). This study showed that IA/IgG was safe and well tolerated in patients with DCM and HF but did not significantly improve LVEF or HF symptoms after 6 months compared with sham treatment. The key secondary endpoint was also similar. Thus, IA/IgG is not a general treatment option in DCM.
Keywords: echocardiography; dilated cardiomyopathy; Left ventricular ejection fraction; Immunoadsorption therapy; immunoadsorption.
Lay summary: This study tested a treatment that removes certain antibodies from the blood (immunoadsorption) in people with a weakened, enlarged heart, a condition which is called dilated cardiomyopathy. Researchers wanted to see if it improved heart function after 6 months. Heart function improved slightly in both the treatment and control groups. However, the treatment did not provide a meaningful extra benefit compared to standard care, though it was found to be safe and well tolerated. Overall, it is not recommended as a routine treatment for this condition.
In infective endocarditis, large vegetation size is associated with embolic events and increased mortality
Tadimi-Tazi S, Muñoz P, Machado-Vilchez M, et al.
Prognostic impact of vegetation size in infective endocarditis.
Eur Heart J Cardiovasc Imaging 2026: jeag061; https://doi.org/10.1093/ehjci/jeag061
The aim was to evaluate the relation between vegetation size and outcomes. Authors’ data come from the Spanish infective endocarditis (IE) registry between 2008 and 2024. From 6525 IE patients, 5000 (76.6%) had vegetations and 3592 (55.1%) had documented vegetation size measurements. Patients were categorized into two groups based on maximum vegetation diameter: <10 mm (1319–36.7%) and ≥10 mm (2273–63.3%). Compared to patients with small vegetations, patients with vegetations ≥10 mm were younger (68 vs. 70 years, P < 0.001), had more frequent right-sided IE (8.0% vs. 4.1%, P < 0.001), less prosthetic valve IE (23.9% vs. 29.9%, P < 0.001), higher surgical rates (55.9% vs. 40.1%, P < 0.001), more embolic events (28.0% vs. 21.4%, P < 0.001), and higher in-hospital mortality (28.3% vs. 19.6%, P < 0.001) and 1-year mortality (35.6% vs. 27.5%, P < 0.001). Large vegetation size was an independent predictor of in-hospital mortality (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.3–1.9, P < 0.001), embolic events (OR 1.34, 95% CI 1.15–1.55, P < 0.001), and 1-year mortality (hazard ratio 1.32, 95% CI 1.17–1.50, P < 0.001). Vegetation size was an independent predictor of in-hospital mortality in left-sided IE (OR 1.7, 95% CI 1.4–2.1, P < 0.001) but not in right-sided IE (OR 1.2, 95% CI 0.7–2.3, P = 0.50). As a conclusion, in patients with IE, large vegetation size is independently associated with embolic events and increased mortality particularly in those with left-sided IE, suggesting the need for more aggressive management in these patients.
Keywords: infective endocarditis, echocardiography, vegetation.
Lay summary: This study examined whether the size of infected growths (“vegetations”) on heart valves affects patient outcomes. Data from over 3,500 patients with measured vegetation size were analysed. Patients were divided into those with small (<10 mm) and large (≥10 mm) vegetations. Those with larger vegetations were slightly younger and more often had right-sided heart infections. They were also more likely to need surgery during their treatment. Large vegetations were linked to a higher chance of complications, especially embolic events (clots traveling in the body), in-hospital mortality and one-year mortality. The risk was particularly strong in infections on the left side of the heart. Overall, larger vegetations indicate a more severe illness and may require more aggressive management.
Reference values for left intraventricular flow dynamics using the Hyper Doppler technique
Beccari R, Cecchetto A, Smarrazzo V, et al.
Evaluation of Left Intraventricular Flow Dynamics Using the Novel Non-contrast HyperDoppler Technique.
Eur Heart J - Imaging Methods and Practice 2026; qyag050; https://doi.org/10.1093/ehjimp/qyag050
The Authors aimed at establishing reference values and reproducibility of key Hyper Doppler LV flow dynamics measures: vortex area, length, depth, intensity, and global kinetic energy dissipation (gKED) in normal subjects. The Authors also explored the influence of physiological and echocardiographic variables on Hyper Doppler measures. This multicenter, international study involved 13 echocardiographic laboratories and an independent echo corelab. A total of 467 normal subjects were enrolled and categorized by gender and age (20–39, 40–59, and 60–79 years): of these, 317 subjects were analyzed at the corelab and 419 on-site using different color Doppler cineloops. Corelab analysis yielded a median value (25th–75th percentiles) of 25.0% (21.1–28.0%) for vortex area, 57.4% (53.3–62.6%) for vortex length, 34.3% (30.7–38.1%) for vortex depth, -31.9% (-28.0% to -35.8%) for vortex intensity, and 0.55 (0.44–0.70) for gKED. Minor age- and gender-related variations were noted in vortex length, depth, and gKED. Excellent reproducibility was shown for each HyperDoppler measure. Physiological behavior of left intraventricular flow dynamics was adequately captured by the HyperDoppler quantitative measures. As a conclusion, reference values for left intraventricular flow dynamics were established using the HyperDoppler technique, which is reproducible and enables the assessment of intracardiac flow dynamics in clinical practice.
Keywords: echocardiography, Doppler, Reproducibility.
Lay summary: This study aimed to define normal reference values for a heart imaging technique called HyperDoppler, which measures blood flow patterns inside the left ventricle. Researchers focused on features like vortex size, shape, strength, and energy loss during blood flow. The study included 467 healthy people from multiple international centers. A central lab analyzed many of the scans to ensure consistency and accuracy. The study established typical ranges for all the measured flow features. Only small differences were found based on age and gender. The measurements were highly reproducible, meaning results were consistent across different settings and observers. The technique successfully captured normal blood flow behavior inside the heart. Overall, HyperDoppler provides reliable reference values and could be useful for assessing heart function in clinical practice.
Left Atrial Strain Predicts Cardiac Outcomes in Moderate Aortic Stenosis
Bak M, Lee SY, Park SJ, et al.
Left Atrial Strain Predicts Cardiac Outcomes in Moderate Aortic Stenosis.
Circ Cardiovasc Imaging 2026; 19:e018451; https://doi.org/10.1161/CIRCIMAGING.125.018451
The study aimed to evaluate prognostic factors, including left atrial strain, and their predictive value for adverse cardiac events in patients with moderate aortic stenosis (AS). In a retrospective cohort of 1125 patients with moderate AS (median age, 74 years; 47.2% women), cardiac remodeling indices, including left atrial reservoir strain (LARS) and left ventricular global longitudinal strain, were assessed using speckle-tracking echocardiography. During a median follow-up of 42.8 months, the 5-year rate of cardiac mortality was 16.7%, while the 5-year rate of the composite endpoint (cardiac mortality and heart failure hospitalization) was 33.9%. LARS emerged as the most sensitive and independent predictor of cardiac death (adjusted hazard ratio, 0.948 per 1% increase; P=0.003) and the composite outcome (adjusted hazard ratio, 0.940 per 1% increase; P<0.001). Notably, the prognostic significance of reduced LARS persisted even after aortic valve replacement (hazard ratio, 2.177 for LARS <20.6% versus ≥20.6%; P=0.024). Furthermore, among all cardiac remodeling parameters analyzed, LARS showed the highest predictive performance for the composite outcome (C-index, 0.586 [95% CI, 0.541-0.632]) compared with other parameters. The Authors concluded that regular assessment of left atrial strain could enhance risk stratification and guide clinical management strategies in patients with moderate AS.
Keywords: echocardiography, aortic stenosis, left atrial strain.
Lay summary: This study investigated patients with moderate aortic stenosis (AS), a condition where the heart's primary valve narrows. Researchers followed 1,125 patients to see if specific heart measurements could predict serious risks like heart failure or death. The study found that Left Atrial Reservoir Strain (LARS)—a measure of how well the heart's upper-left chamber stretches—is the most reliable predictor of a patient's future health. As the atrium loses its elasticity, the risk of cardiac "events" rises significantly. Crucially, this risk remains high even if the patient later undergoes surgery to replace the damaged valve. The findings suggest that the left atrium acts as an "early warning system." By regularly measuring LARS through non-invasive imaging, doctors can better identify high-risk patients and refine treatment strategies before the condition reaches a critical stage.
CMR
Combined aortic and mitral regurgitation is associated with increased ventricular remodeling and adverse events, compared with isolated aortic regurgitation
Malahfji MI, Saeed M, Nguyen DT, et al.
Cardiac Remodeling and Outcomes of Patients With Combined Aortic and Mitral Regurgitation.
JACC Cardiovasc Imaging 2026; 19:180-193; https://doi.org/10.1016/j.jcmg.2025.09.022
This multicenter observational study evaluated 915 patients with at least moderate aortic regurgitation (AR) on cardiac magnetic resonance (CMR) to determine how concomitant mitral regurgitation (MR) —even of moderate degree— affects cardiac remodeling and outcomes. Patients with prior valve intervention, relevant stenosis, cardiomyopathy, or complex congenital disease were excluded. Among the cohort (median age 61 years, 79.5% male), 27.4% had combined AR/MR, and 14.2% had at least moderate MR. Concomitant ≥moderate MR was associated with a steeper increase in indexed LV end‑diastolic and end‑systolic volumes and a greater decline in LV ejection fraction for each increment in AR severity, compared with isolated AR. Over a median 3.0‑year follow‑up, ≥moderate MR conferred a higher hazard for all‑cause death (HR 2.77; 95% CI: 1.91-4.01; P < 0.001) and carried more than double the risk of death or heart failure (HR 2.62, 95% CI: 1.87-3.67; P < 0.001) compared to isolated AR. This elevated risk remained evident in asymptomatic or only mildly symptomatic patients, even after adjustment and propensity score matching. The authors conclude that combined AR/MR on CMR is far from benign and identifies a higher‑risk phenotype with more adverse remodeling and outcomes, suggesting that asymptomatic patients with moderate AR and MR may merit closer follow‑up and potentially earlier intervention..
Keywords: cardiac magnetic resonance, aortic regurgitation, mitral regurgitation, multivalvular disease, left ventricular remodelling, risk stratification.
Lay summary: This study followed more than 900 people with leakage of the aortic valve, some of whom also had leakage of the mitral valve. Using MRI, they measured heart size, pumping function, and how much blood leaked across each valve. Patients with leakage through both valves showed more enlargement and weakening of the heart over time than those with leakage of the aortic valve alone. They also had a higher risk of dying or being admitted to hospital with heart failure, even when they had only moderate leakage and few or no symptoms. These findings suggest that having two leaking valves is more dangerous than having just one, and that “moderate” leakage of both valves should not be considered harmless. Patients with this combination may need closer monitoring and possibly earlier treatment, rather than simple watchful waiting.
CMR-derived aortic regurgitation fraction is strongly predictive of clinical outcomes
Bali T, Gall A, Bana A, et al.
The role of CMR in the timing of aortic valve interventions and risk stratification in aortic regurgitation: a systematic review and meta-analysis.
Eur Heart J Cardiovasc Imaging 2026; 27:162-173; https://doi.org/10.1093/ehjci/jeaf349
This systematic review and meta-analysis included 12 observational studies (8 in the meta-analysis; n=1996) evaluating cardiovascular magnetic resonance (CMR)–derived aortic regurgitant fraction (ARF) for timing of aortic valve intervention and risk stratification in chronic aortic regurgitation (AR). Eight studies were pooled with a random‑effects model; ARF thresholds ranged from 30–43% (mean 33.7%), with follow‑up of 2–5.1 years. The primary endpoint was a composite of clinical outcomes (valve intervention, heart failure hospitalization, or death), analysed as hazard ratios for ARF above study‑specific cut‑offs, with overall risk of bias rated low to moderate. Across studies, ARF >33% was associated with adverse events (pooled HR 4.12; 95% CI 2.31–7.34; P<0.01). However, this arises in the context of significant heterogeneity (I²=98%) and a wide range of individual hazard ratios (from 1.04 to 24.59), reflecting marked differences in patient populations, ARF cut‑off definitions (30–43%) and endpoints. Results appeared broadly consistent across native chronic AR and post‑TAVI cohorts, yet the underlying remodelling biology likely differs between these groups, which may limit extrapolation of a single ARF cut‑off across all settings. The authors conclude that CMR‑derived ARF is a powerful prognostic marker and that ARF > 33% identifies patients at substantially increased risk, supporting its integration into clinical frameworks.
Keywords: cardiac magnetic resonance, aortic regurgitation, aortic regurgitant fraction, risk stratification, valve intervention timing.
Lay summary: Researchers pooled data from 1996 patients with aortic valve regurgitation and used MRI‑based flow measurements to quantify how much blood leaks back through the valve. They found that once the leak fraction rises to about one‑third or more of the forward flow, the risk of needing valve surgery, developing heart failure, or dying increases more than four‑fold. This work suggests that MRI‑based leak measurements could help doctors decide earlier and more precisely when aortic valve surgery should be recommended.
Hepatic extracellular volume fraction is a novel prognostic marker in patients with tricuspid regurgitation
Villar-Calle P, Zhang RS, Naami E, et al.
Hepatic Extracellular Volume Fraction by CMR: A Novel Prognostic Marker in Tricuspid Regurgitation.
Circ Cardiovasc Imaging 2026; 19:e018988; https://doi.org/10.1161/CIRCIMAGING.125.018988
The study investigated how tricuspid regurgitation (TR) leads to systemic venous congestion and congestive hepatopathy, by measuring hepatic extracellular volume fraction (ECV) on cardiac magnetic resonance. The study enrolled 234 patients (mean age, 65.6±15.8 years; 46.2% men) with at least moderate TR who underwent cardiac magnetic resonance with hepatic pre- and post-contrast T1 mapping calculation. Mean hepatic ECV was 37.7±9.0%, with tertile cutoffs at 32.5% and 41.3%. Higher hepatic ECV tertiles were associated with worse biventricular function and greater TR severity. Right ventricular ejection fraction decreased across tertiles (48.2% versus 48.5% versus 40.3%, P<0.001), while right ventricular end-diastolic volume index increased (107.4 versus 105.4 versus 127.4 mL/m², P<0.001). During a mean follow-up of 2.2 years, 43 (18.4%) deaths occurred. Mortality increased across hepatic ECV tertiles: 12.8% versus 11.5% versus 30.8% (P=0.002 for trend). In multivariable Cox regression adjusting for age, right ventricular dysfunction, and severe TR, hepatic ECV tertiles remained independently predictive of mortality (hazard ratio, 1.62 [95% CI, 1.06–2.48]; P=0.027). Forward stepwise analysis yielded significant incremental prognostic value beyond traditional TR risk factors, improving model discrimination from χ²=24.4 to 30.1 (P=0.02). The Authors concluded that hepatic ECV is a novel prognostic marker that provides incremental risk stratification in TR and has potential to impact therapeutic decision-making in the era of expanded treatment options for TR.
Keywords: magnetic resonance; extracellular volume; hepatic congestion; tricuspid regurgitation; prognosis.
Lay summary: This study explores the "heart-liver connection" in patients with tricuspid regurgitation (TR), a condition where a leaky heart valve causes blood to flow backward, creating fluid congestion in the liver. Using MRI scans, researchers measured hepatic extracellular volume (ECV), an index of scarring and fluid buildup in the liver. They found that patients with higher liver ECV scores had weaker heart function and a significantly higher risk of death. Crucially, this liver measurement predicted survival better than traditional heart tests alone. Even after accounting for age and heart severity, liver ECV remained a powerful predictor of mortality. The researchers conclude that checking the liver's health via MRI can help doctors better identify high-risk patients and decide when to intervene with new heart valve treatments.
Ischemia severity by CMR has a stronger association with all ISCHEMIA trial endpoints compared with SPECT/echo
Kwong RY, Heydari B, Abbasi S, et al.
Stress Cardiac Magnetic Resonance Ischemia Burden and Cardiovascular Events: Post-Hoc Analysis From the ISCHEMIA Trial.
JACC Cardiovasc Imaging 2026; 19:326-341; https://doi.org/10.1016/j.jcmg.2025.10.015
This study compared the prognostic value of stress cardiac magnetic resonance (CMR) vs alternative testing by either single-photon emission computed tomography or stress echocardiography (SPECT/echo) in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial.
Ischemia and infarct extent, measured by either CMR or SPECT/echo, were each associated with the trial's primary outcome of cardiovascular death, nonfatal myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest, at a median follow-up of 3.37 Years. Compared with SPECT/echo (n = 5,627), CMR participants (n = 313) were not different in key demographic factors but were more likely to have severe ischemia (57% vs 38%; P < 0.001). Ischemia severity (no/mild, moderate, severe) by CMR core laboratory was associated with cumulative 4-year event rates of all trial-specific endpoints, including the primary outcome (P = 0.042), cardiovascular death/MI (P = 0.041), and nonfatal MI (P = 0.03), but SPECT/echo ischemia severity was not. The association between ischemia extent and the primary endpoint differed by imaging modality, with each additional ischemic segment on CMR associated with a 13% increase in hazard. In participants assigned to initial conservative management who had no/mild ischemia on imaging, 4-year rates of invasive referral and coronary revascularization were lower in the CMR (16.7% and 0%, respectively) than SPECT/echo (31% and 13.3%, respectively). The Authors concluded that ischemia severity by CMR had a stronger association with all ISCHEMIA trial endpoints compared with SPECT/echo.
Keywords: cardiac magnetic resonance, ISCHEMIA trial; cardiovascular events; stress cardiac magnetic resonance; coronary artery disease.
Lay summary: This study compared different heart imaging methods used in the ISCHEMIA trial to see which best predicts future heart problems. Researchers compared stress CMR (a high-resolution MRI) against more traditional tests like SPECT (nuclear scans) or stress echoes (ultrasound). Stress CMR was significantly more accurate at predicting major events like heart attacks or cardiovascular death. Specifically, each additional "damaged" segment found on an MRI increased a patient's risk by 13%, whereas traditional tests weren't as precise in their forecasting. Furthermore, for patients treated with medicine rather than surgery, those who had "low-risk" MRI results were far less likely to need invasive procedures later compared to those cleared by traditional scans. The authors conclude that Stress CMR provides a clearer picture of a patient's risk, potentially preventing unnecessary surgeries and better identifying those in danger.
Late gadolinium enhancement phenotype predicts prognosis better than LGE burden in patients with cardiac sarcoidosis
Mengesha B, Rivard L, Kadoya Y, et al.
Comparing the Prognostic Utility of Late Gadolinium Enhancement Burden and Phenotype in Patients with Cardiac Sarcoidosis; a Prospective Cohort Study Open Access.
Eur Heart J - Imaging Methods and Practice 2026; qyag056; https://doi.org/10.1093/ehjimp/qyag056
Cardiac Sarcoidosis (CS) is associated with a significant risk of ventricular arrhythmias (VAs). This study aimed to compare the prognostic value of quantitative late enhancement (LGE) burden and LGE phenotype in a prospectively collected CS cohort with long-term follow-up. Secondary aims were to compare the reproducibility and speed of LGE burden quantification and LGE phenotyping.
A total of 206 patients (112/206 (54.4%) with CS and 94/206 (45.6%) with extra-cardiac sarcoidosis) were included. Pathology-frequent LGE phenotype, defined as LGE with at least one of four features (subepicardial, multifocal, septal, or right ventricular free wall involvement), occurred in 85/206 (41.3%) and 22/206 (10.7%) patients had sustained VA during a 5.1±2.8-year follow-up. All events occurred in patients with pathology-frequent phenotype. LGE phenotype and categorical LGE% had similar high discriminative accuracy in predicting future VA; however, only LGE phenotyping had 100% NPV. Interobserver reproducibility of LGE phenotype was very high (Cohen's kappa=0.97, p<0.001) and much better than LGE categorical quantification (Cohen's kappa =0.41, p=0.04). LGE phenotyping was on average five-fold faster (1.75 ± 0.9 minutes compared to 10 ± 2.2 minutes, p=0.012). This study demonstrates the prognostic importance of the pathology-frequent phenotype of LGE, with a 100% NPV and a much higher interobserver reproducibility and speed of analysis than LGE quantification.
Keywords: cardiac magnetic resonance, sarcoidosis, late enhancement; prognosis; arrhythmias.
Lay summary: This study focuses on cardiac sarcoidosis (CS), a disease that can cause dangerous irregular heartbeats (arrhythmias). Researchers used MRI scans to compare two ways of assessing heart scarring: measuring the total amount of scar tissue (LGE burden) versus identifying specific patterns or "shapes" of scarring (LGE phenotype). The study followed 206 patients for over five years. They found that a specific "pathology-frequent" phenotype—scarring in certain high-risk locations—was a perfect predictor: every single patient who experienced a dangerous heart rhythm fell into this category. Beyond accuracy, identifying these scarring patterns was five times faster for doctors to perform and much more consistent between different experts than measuring scar volume.
Diagnostic performance of coronary magnetic resonance angiography (CMRA) with an improved spatial resolution of 0.7 mm³ compared to 0.9 mm³
Wood G, Kabel A, Uglebjerg Pedersen A, et al.
Improvements in the spatial resolution of Coronary Magnetic Resonance Angiography enhance the diagnostic performance in comparison to Quantitative Coronary Angiography.
Eur Heart J - Imaging Methods and Practice 2026; qyag057; https://doi.org/10.1093/ehjimp/qyag057
Automated image acquisition in combination with a 2D image navigator allow for an improved spatial resolution of Coronary Magnetic Resonance Angiography (CMRA) that is approaching that of coronary computed tomography angiography. This study investigated whether this increased spatial resolution significantly improves the diagnostic performance of CMRA in detecting the severity of coronary artery disease (CAD). CMRA with 0.7 mm³ spatial resolution was compared to CMRA with 0.9 mm³ spatial resolution for the detection of CAD in 81 patients, using 2-dimensional quantitative coronary angiography as the reference standard. On a per-patient basis, the sensitivity of 0.7 mm3 CMRA was significantly better than 0.9 mm3 CMRA to detect ≥50% stenosis (0.885 vs 0.721, p = 0.01), whilst the negative predictive value showed no difference (0.500 vs 0.320, p = 0.10). On a per vessel basis, the sensitivity (0.716 vs 0.558, p = <0.01), negative predictive value (NPV) (0.857 vs 0.802, p = 0.01) and Area under the curve (AUC) (0.742 vs 0.682, p = 0.04), were significantly better for 0.7 mm3 CMRA to detect ≥50% stenosis. In conclusion, CMRA with an improved spatial resolution of 0.7 mm³ compared to 0.9 mm³ was superior for the detection of ≥50% stenosis.
Keywords: cardiac magnetic resonance; magnetic resonance angiography; coronary artery disease; cardiovascular events.
Lay summary: This study evaluated whether higher-definition MRI scans can better detect coronary artery disease (CAD). Historically, CT scans have provided clearer images than MRIs, but new "automated" MRI technology is closing that gap. Researchers compared two levels of MRI detail: a high-resolution version (0.7 mm³) and a standard version (0.9 mm³). By testing 81 patients, they found that the higher-resolution MRI was significantly better at spotting serious arterial narrowing (at least 50% blockage). It was more sensitive and provided a more accurate "area under the curve," a statistical measure of overall diagnostic power. This improved resolution helps ensure that significant blockages aren't missed, making MRI a much more competitive tool for diagnosing CAD.
Cardiac CT
Colchicine slows overall coronary plaque burden progression on serial CCTA
Budoff MJ, Bhandari M, Iskander B, et al.
Effect of colchicine on progression of known coronary atherosclerosis in patients with stable coronary artery disease: EKSTROM randomized placebo controlled trial.
Eur Heart J Cardiovasc Imaging 2026; jeag028; https://doi.org/10.1093/ehjci/jeag028
EKSTROM was a randomized, double-blind, placebo-controlled trial evaluating whether low-dose colchicine (0.5 mg daily) modifies coronary atherosclerosis progression on serial coronary CT angiography over 12 months in patients with stable coronary artery disease. The prespecified primary endpoint—change in low-attenuation plaque (LAP) volume—was neutral, with no significant between-group difference. In contrast, colchicine was associated with less progression in overall plaque burden, quantified as percent atheroma volume (PAV), and a reduction in dense calcified plaque; trends toward regression of non-calcified and fibro-fatty plaque were also reported. Inflammatory biomarkers decreased numerically but were not significantly different between groups. The study is best interpreted as hypothesis-generating: the negative primary endpoint and the rarity of LAP in a well-treated cohort limit inference about ‘high-risk’ plaque modification, but the signal on global plaque burden supports further evaluation of anti-inflammatory strategies using quantitative CCTA endpoints and, crucially, linkage to clinical outcomes.
Keywords: CT; CCTA; coronary plaque; plaque progression; low-attenuation plaque; percent atheroma volume; colchicine; inflammation; stable coronary artery disease.
Lay summary: In this trial, people with stable coronary artery disease had heart CT scans at the start and after 12 months while taking either low-dose colchicine (an anti-inflammatory medicine) or a placebo. The main CT measure of ‘high-risk’ soft plaque did not change differently between groups. However, the overall amount of plaque increased less in those taking colchicine, and the drug was generally well tolerated. These findings suggest colchicine may slow overall plaque build-up, but larger studies are needed to confirm whether these CT changes translate into fewer heart attacks or other clinical benefits.
In symptomatic individuals with zero calcium score, elevated LDL-cholesterol is associated with higher risk of non-calcified plaque and with adverse outcomes
Andersen MH, Jensen JM, Kanstrup H, et al.
Low-density lipoprotein cholesterol and cardiovascular risk in the absence of calcifications on computed tomography: the Western Denmark Heart Registry.
Eur Heart J 2025; 46:5062-5072; https://doi.org/10.1093/eurheartj/ehaf497
This large registry study evaluated cardiovascular risk in patients with zero coronary artery calcium (CAC) on CT. The study cohort from the Western Denmark Heart Registry included 23 777 symptomatic individuals (median age 54 years, 61% women) undergoing coronary computed tomography angiography (CCTA) from 2008-2021, with a 7.1-year median follow-up time. Outcomes included adjusted odds ratios (aOR) for non-calcified plaque on CCTA and adjusted hazard ratios (aHR) for coronary heart disease (CHD). Per 1 mmol/L higher LDL-C, the overall aOR for non-calcified plaques was 1.21 [95% confidence interval (CI) 1.16-1.27]; corresponding values were 1.39 (1.23-1.56) at age ≤45, 1.22 (1.14-1.31) at age 46-60, and 1.11 (1.02-1.21) at age >60. During follow-up, 299 (1%) had a CHD event. Per 1 mmol/L higher LDL-C, the overall aHR was 1.28 (1.13-1.46) for CHD; corresponding values were 1.37 (1.04-1.82) at age ≤45, 1.24 (1.04-1.49) at age 46-60, and 1.26 (1.00-1.60) at age >60. In conclusion, in symptomatic individuals with CAC = 0, elevated LDL-C is associated with higher risk of non-calcified plaque and with higher relative risk of future CHD events, most pronounced at age ≤45 years. These findings emphasize the limitations of CAC alone and support the role of advanced CT plaque analysis for comprehensive risk assessment.
Keywords: Coronary Calcium; CT; LDL Cholesterol; Risk Stratification; Non-calcified Plaque.
Lay summary: This study analyzed over 23,000 patients with chest pain who had a "zero" calcium score on their heart scans, a result typically associated with a very low risk of heart disease. Researchers discovered that despite having no hardened calcium in their arteries, patients with high "bad" cholesterol (LDL-C) remained at significant risk for heart complications. Higher LDL-C levels were directly linked to the presence of non-calcified "soft" plaques, which are invisible to standard calcium scans but can still lead to heart attacks. This risk was particularly pronounced in younger adults aged 45 and under. The findings suggest that relying solely on calcium scores can provide a false sense of security, especially in younger symptomatic patients.
Adding a delayed phase to cardiac computed tomography for coronary artery evaluation holds prognostic value
Oguni T, Izumiya Y, Oda S, et al.
Does adding a delayed phase to cardiac computed tomography for coronary artery evaluation have prognostic value?
Eur Heart J Cardiovasc Imaging 2026; jeag018; https://doi.org/10.1093/ehjci/jeag018
Cardiac computed tomography (CCT) assesses coronary anatomy and enables delayed phase imaging, including extracellular volume fraction (ECV) for diffuse myocardial fibrosis and late iodine enhancement (LIE) for focal myocardial replacement fibrosis. This study evaluated LIE and ECV in 1,207 patients undergoing CCT for coronary artery assessment and examined their association with clinical outcomes. Primary outcome was a composite of all-cause death and unplanned cardiovascular hospitalizations; secondary outcome was cardiovascular events, defined as cardiac death and unplanned cardiovascular hospitalization. During a mean 26.0 ± 19.1 month follow-up, patients with LIE and elevated ECV showed increased risk for the primary (HR 1.84, 95% confidence interval [CI] 1.22-2.79) and secondary endpoint (HR 2.67, 95% CI 1.32-5.41). In conclusion, in patients undergoing CCT for coronary artery evaluation, coexistence of LIE and elevated ECV is associated with higher risk of cardiovascular events and their assessment may provide synergistic prognostic value.
Keywords: Cardiac CT; Coronary Artery Disease; Prognosis; Tissue Characterization; extracellular volume; late iodine enhancement.
Lay summary: This study investigated how specialized heart scans (cardiac CT) can predict future health risks by looking for two types of heart scarring (focal and diffuse, called LIE and ECV, respectively). Researchers tracked 1,207 patients for over two years to see if LIE and ECV linked to serious health events.
The results showed that patients who had both types of scarring simultaneously were at significantly higher risk for death or emergency heart-related hospitalizations. Specifically, they were nearly twice as likely to experience a major health setback compared to those without. The study concludes that measuring these "hidden" scars during a routine scan provides vital clues about a patient’s future heart health.
CCTA can longitudinally track plaque development and progression, providing insights into disease dynamics beyond baseline stenosis
Tantawy S, Xu Z, Gianni U, et al.
New atherosclerotic plaque formation by coronary CTA in suspected coronary artery disease patients: results from the PARADIGM Registry.
Eur Heart J Cardiovasc Imaging 2026; 27: jeaf367.317; https://doi.org/10.1093/ehjci/jeaf367.317
In this sub-analysis of the PARADIGM registry, quantitative CCTA was repeated after ≥2 years in 1343 patients (age 60.4±9.4 years, 42.8% females), of whom 334 (24.9%) patients had no baseline plaque (BP). Over 3.3 years (IQR 2.6, 4.8), new lesions developed in 35% of patients without and 46.7% of patients with BP (p=0.0003). New obstructive lesions ≥50% were rare, observed in 3(0.9%) in those without and 7(0.7%) in those with BP. New high risk plaques occurred in 105 (18%) patients with new lesion with no significant difference among both groups, however, positive remodeling was more in patients with BP (OR = 2.04 (95% CI 1- 4.03), p=0.044). The most common site of new lesions was the left anterior descending artery (60%) in absence of BP and right coronary artery (47%) in presence of BP. Adjusting for covariates and CT interval, the presence of BP (OR 1.84; 95%CI 1.38, 2.46, p<0.001), diabetes (OR 1.38; 95%CI 1.03, 1.85) and higher body mass index (OR 1.04 per kg/m2; 95%CI 1.01, 1.08) increased the likelihood of new lesion formation. In conclusion, new lesions can be observed by CCTA in over 1/3 of patients without and nearly 1/2 of patients with baseline plaque, although new obstructive lesions are infrequent.
Keywords: Coronary CT Angiography; Plaque Progression; Atherosclerosis; Longitudinal Imaging; PARADIGM.
Lay summary: This study used repeated heart scans (CCTA) over three years to track the development of new arterial blockages (plaque) in 1,343 patients. Researchers found that plaque is quite dynamic: new lesions appeared in 35% of people who started with clear arteries and nearly 50% of those who already had some buildup.
While new plaque was common, it rarely grew fast enough to cause severe, high-grade blockages within the study period. Factors like existing plaque, diabetes, and a higher body mass index significantly increased the chances of new lesions forming. Interestingly, the location of new plaque shifted depending on the patient's history. Overall, the findings suggest that while new buildup happens frequently, it usually progresses slowly.
PCCT provides CMR-comparable assessment of ventricular geometry, function, and myocardial fibrosis/ECV while enabling coronary angiography
De Gori G, Aimo A, Occhipinti M, et al.
Photon-Counting Computed Tomography for Tissue Characterization in Patients With a Left Ventricular Hypertrophic Phenotype.
JACC Cardiovasc Imaging 2026; S1936-878X(26)00141-5; https://doi.org/10.1016/j.jcmg.2026.02.019
Photon-counting computed tomography (PCCT) combines high spatial resolution with spectral imaging and can provide morphologic, functional, and tissue assessment in hypertrophic hearts. In this study, 182 patients with left ventricular hypertrophy (72 with hypertrophic cardiomyopathy, 47 with amyloid transthyretin cardiomyopathy, and 63 with secondary LVH) underwent PCCT including late iodine enhancement (LIE) and PCCT-derived extracellular volume (ECV). PCCT differentiated etiologies through distinctive tissue patterns. Transthyretin cardiac amyloidosis showed the highest left ventricular mass index (median: 104 g/m2), the greatest LIE extent (median: 17/17 segments), and the highest ECV (median: 47%). Hypertrophic cardiomyopathy showed patchy fibrosis (median 4 enhanced segments) with intermediate ECV (31%), whereas secondary LVH displayed minimal enhancement (median: 0 segments) and the lowest ECV (28%). Eighty-three patients (46%) also underwent CMR: in paired examinations, PCCT correlated closely with CMR for left ventricular mass index and left ventricular ejection fraction (r = 0.963 and r = 0.947; P < 0.001 for both) for ECV (r = 0.868; P < 0.001) and for LIE extent (r = 0.998; P < 0.001). PCCT provides CMR-comparable assessment of ventricular geometry, function, and myocardial fibrosis/ECV while enabling coronary angiography, supporting its use when CMR is contraindicated, impractical, or nondiagnostic.
Keywords: photon-counting; computed tomography; late enhancement; left ventricular hypertrophy.
Lay summary: Researchers have found that a new imaging technology called photon-counting CT (PCCT) is a powerful tool for diagnosing why a patient’s heart muscle has become abnormally thick. By measuring "extracellular volume" (space between heart cells) and scarring, the scan successfully distinguished between three different conditions: cardiac amyloidosis (showing the most severe scarring), hypertrophic cardiomyopathy (showing patchy scarring), and secondary thickening (showing minimal changes). The study compared PCCT results to the current "gold standard" Cardiac MRI, and found the two methods were nearly identical in accuracy. This is a major breakthrough because PCCT can also check for coronary artery disease and provides a high-quality alternative for patients who cannot undergo an MRI due to implants or other restrictions.
Coronary computed tomography angiography-derived fractional flow reserve: comparison between standard resolution and ultrahigh resolution imaging
Portolan L, Kotronias RA, Andreaggi S, et al.
Standard and Ultrahigh Resolution Photon-Counting Coronary CTA-Derived FFR Against Invasive FFR Assessment.
JACC Cardiov Imag 2026; S1936-878X(26)00110-5; https://doi.org/10.1016/j.jcmg.2026.02.014
This study compared standard resolution (SR) vs. (UHR) ultrahigh resolution photon-counting coronary computed tomography angiography (PCCTA). Thirty-two patients with a clinical indication for invasive coronary artery underwent research PCCTA with both SR and UHR acquisitions before ICA. Invasive FFR of intermediate coronary stenoses was measured. SR-PCCTA- and UHR-PCCTA-derived FFR were computed using an on-site, machine-learning-based prototype and compared with invasive FFR. Invasive FFR, SR-PCCTA-, and UHR-PCCTA-derived FFR were available for 54 vessels. Both SR-PCCTA-derived (ρ: 0.490; P < 0.001) and UHR-PCCTA-derived FFR (ρ: 0.728; P < 0.001) correlated well with invasive FFR. Unlike SR-PCCTA, UHR-PCCTA-derived FFR maintained its correlation in severely calcific (ρ: 0.577; P = 0.039) and diffusely diseased vessels (ρ: 0.772; P = 0.009). UHR-PCCTA-derived FFR outperformed SR-PCCTA in diagnostic accuracy (AUC: 0.93 vs 0.80; P for comparison = 0.012) and hemodynamic significance classification (Cohen's κ: 0.70 vs 0.50). In conclusion, both SR-PCCTA- and UHR-PCCTA-derived FFR correlated with invasive FFR, but UHR-PCCTA outperformed SR-PCCTA in diagnostic accuracy and hemodynamic significance classification.
Keywords: photon-counting coronary computed tomography; fractional flow reserve; invasive coronary artery; coronary artery disease.
Lay summary: This study evaluated whether a newer, Ultrahigh Resolution (UHR) version of photon-counting CT scans is better at determining if a heart artery blockage is actually restricting blood flow. Researchers compared two CT methods—Standard Resolution (SR) and UHR—against the "gold standard" invasive procedure (Fractional Flow Reserve or FFR). While both CT methods performed well, the UHR scans were significantly more accurate. Notably, UHR remained reliable even in challenging cases where arteries were severely hardened by calcium or extensively diseased—areas where standard scans often fail. In conclusion, UHR-CT provides a much clearer picture and more precise data, potentially allowing patients to avoid invasive diagnostic heart procedures by using this advanced non-invasive imaging instead.
Nuclear cardiology
Interaction between Atrial metabolic Avidity and function in cardiac sarcoidosis: a multimodality imaging study
Kassar A, Haykal R, Chamoun N, et al.
Atrial FDG Avidity is Associated with Reduced Atrial Strain and Contractility Independent of Atrial Fibrillation and Cardiac Sarcoidosis.
Eur Heart J - Imaging Methods and Practice 2026; qyag037; https://doi.org/10.1093/ehjimp/qyag037
This study aimed at assessing the interaction between left atrial (LA) metabolic activity assessed through 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and LA function evaluated with cardiac magnetic resonance (CMR) in 120 patients submitted to this combined anatomic-functional cardiac evaluation because of suspected cardiac sarcoidosis (CS). LA structure and function were assessed with the computation of the LA volume index (LAVi) and strain data, respectively, while LA metabolic activity were expressed with the SUVmax and atrial target-to background ratio (aTBR) from FDG-PET datasets. Results indicated that LA strain negatively correlated with both SUVmax (P< 0.001) and moderately with aTBR (P< 0.001). Similar correlations were observed for between LAVi and both SUVmax and aTBR. The correlations persisted after adjusting for demographics, cardiovascular risk factors, the presence of cardiac sarcoidosis and atrial fibrillation. Interestingly, AF patients exhibited reduced LA strain and higher FDG-PET activity as a possible measure of atrial myopathy. The Authors concluded that, increased atrial FDG avidity is a significant predictor of adverse lA structural and functional remodeling as exemplified by an impaired strain and enlarged indexed volume. This metabolic abnormality might precede atrial myopathy in patients without overt cardiac disease and AF.
Keywords: positron emission tomography; cardiac magnetic resonance; multimodality imaging; cardiac sarcoidosis; atrial function.
Lay summary: This study evaluated 120 patients who underwent both FDG-PET and CMR to examine the association between left atrial (LA) metabolic activity and mechanical function. Increased LA FDG uptake was significantly associated with impaired atrial structure and mechanics. Elevated FDG avidity may therefore represent a marker of subclinical atrial myopathy, potentially reflecting inflammatory activation or metabolic stress. These results support a mechanistic link between atrial metabolic remodeling and impaired LA performance and suggest a potential role for metabolic imaging in detecting early atrial dysfunction before clinically apparent disease develops.
Development of a novel radiotracer for the non-invasive identification of high-risk atherosclerotic plaques
George P Keeling GP, Wang X, Chen W, et al.
Development and validation of an activatable PET radiotracer reporting extracellular myeloperoxidase activity for the detection of unstable atherosclerotic plaque.
Npj Imaging 2026; 4:23; https://doi.org/10.1038/s44303-026-00156-9
Extracellular arterial activity of the pro-inflammatory enzyme myeloperoxidase (MPO) destabilizes atherosclerotic plaque and associates with future atherothrombosis. In this preclinical study, the Authors describe [68Ga]Ga-IEMA, a NODAGA-based positron emission tomography (PET) radiotracer that provides an index for extracellular MPO activity. Synthesis of [68Ga]Ga-IEMA was achieved in five steps and with high radiolabelling efficiency. [68Ga]Ga-IEMA self-oligomerized and bound to proteins upon exposure to enzymatically active MPO, did not cross-cell membranes and was stable in human serum in vitro, while [68Ga]Ga-IEMA had favourable blood kinetics and stability in circulation in vivo. In a mouse model of plaque instability, [68Ga]Ga-IEMA PET imaging revealed enhanced signal in unstable compared with stable plaque and plaque-free arteries. These data indicate that [68Ga]Ga-IEMA is a promising translational candidate for the non-invasive identification of high-risk atherosclerotic plaques and the evaluation of therapies targeting arterial inflammation.
Keywords: Positron emission tomography; Coronary plaque; Atherosclerosis; myeloperoxidase.
Lay summary: Researchers have developed a new medical imaging tool, a radioactive tracer called "[68Ga]Ga-IEMA", to identify high risk plaques in the coronary arteries. Heart attacks are often caused by unstable arterial plaques that rupture. This instability is driven by "MPO" (myeloperoxidase), an enzyme that promotes inflammation. While MPO is a known red flag, it has been difficult to see its activity inside a living body. This study shows that the new tracer specifically reacts with active MPO outside of cells, "locking" into place to highlight dangerous areas during a PET scan. In animal tests, the tracer successfully distinguished high-risk, unstable plaques from stable ones. This non-invasive method could soon help doctors identify patients at high risk for heart attacks and monitor how well anti-inflammatory treatments are working.
Cardiac fibroblast activation heterogeneity assessed by FAPI PET radiomics in hypertrophic cardiomyopathy
Song H, Ding J, Zhao J, et al.
Prognostic value of cardiac fibroblast activation heterogeneity assessed by FAPI PET radiomics in hypertrophic cardiomyopathy: a proof-of-concept study
Open Heart 2026; 13:e003537; https://doi.org/10.1136/openhrt-2025-003537
Hypertrophic cardiomyopathy (HCM) is associated with an increased risk of sudden cardiac death (SCD), and myocardial fibrosis plays a central role in the pathophysiology process. Radiolabelled fibroblast activation protein inhibitor (FAPI) positron emission tomography computed tomography (PET) imaging enables visualisation of activated fibroblasts and may detect earlier stages of myocardial fibrosis than conventional structural imaging. This study developed a radiomics model based on FAPI PET imaging for stratifying predicted 5-year sudden cardiac death (SCD) risk in 92 patients with hypertrophic cardiomyopathy (HCM). Two radiomics features were selected from myocardial regions of interest using elastic net regression to construct the model. The apparent area under the receiver operating curve of the radiomics model was 0.839, which decreased to 0.772 after bootstrap correction and became comparable to the conventional imaging metric. Sensitivity analysis demonstrated stable model performance after excluding PET/CMR data. The Authors concluded that FAPI PET-based radiomics is feasible for quantifying myocardial fibroblast activation heterogeneity and shows potential for predicted SCD risk stratification in HCM. These findings should be interpreted as proof-of-concept and require validation in larger prospective cohorts with clinical endpoints.
Keywords: Positron emission tomography; fibroblast activation protein inhibitor; hypertrophic cardiomyopathy; sudden cardiac death.
Lay summary: Hypertrophic cardiomyopathy (HCM) causes heart muscle thickening and scarring (fibrosis), which can trigger sudden cardiac death. This study tested a new way to predict this arrhythmic risk using a specialized PET scan and a tracer called FAPI (fibroblast activation protein inhibitor). While standard imaging shows existing scars, FAPI PET highlights activated fibroblasts—the cells actively creating new scar tissue. Researchers used "radiomics" (AI analysis of imaging patterns) to build a model predicting a patient’s 5-year risk of sudden death. The model proved accurate, matching traditional methods while potentially detecting disease activity earlier. Though currently a "proof-of-concept" requiring more study, this approach suggests that AI-enhanced PET scans could one day help doctors better identify and protect high-risk heart patients.
Mechanical dyssynchrony and perfusion heterogeneity independently predict adverse LV remodeling, irrespective of left bundle branch block
Brandão SCS, Joseph L, Brown JM, et al.
Mechanical Dyssynchrony and Septal-Lateral Perfusion Heterogeneity Predict Adverse Left Ventricular Remodeling Beyond ECG-Defined LBBB.
Eur Heart J Cardiovasc Imaging 2026; jeag081; https://doi.org/10.1093/ehjci/jeag081
This study aimed to assess how mechanical dyssynchrony and perfusion heterogeneity relate to left ventricular (LV) remodeling and function in 233 patients with left bundle branch block (LBBB) and 932 matched controls who underwent PET myocardial perfusion imaging. Compared with controls, LBBB patients had greater dyssynchrony (56% vs. 40%), larger LV volumes, and ejection fraction (EF, 54% vs. 67%) (all p<0.001), as well as higher stress coronary vascular resistance (CVR, 37 vs. 34 mmHg/mL·min⁻¹·g⁻¹), and lower myocardial blood flow (MBF, 2.4 vs. 2.6 mL/min/g), myocardial flow reserve (MFR, 2.4 vs. 2.6), and septal-to-lateral MBF ratio (SLR, 0.95 vs. 1.00) (all p<0.05). In multivariable regression, mechanical dyssynchrony (phase entropy) and SLR independently predicted LV volumes and EF, with adverse effects of SLR reduction amplified in LBBB (interaction p<0.01). In Cox analysis, phase entropy (HR:1.02, p=0.01), MFR (HR:0.62, p<0.001), and LVEF (HR:0.97, p<0.001) were independently associated with death or heart failure hospitalization, whereas LBBB was not. In conclusion, mechanical dyssynchrony and perfusion heterogeneity independently predict adverse LV remodeling, irrespective of LBBB.
Keywords: Left bundle branch block; Mechanical dyssynchrony; Microvascular dysfunction; PET; Phase entropy.
Lay summary: This study examined how "out-of-sync" heart contractions (mechanical dyssynchrony) and uneven blood flow (perfusion heterogeneity) affect heart health in 233 patients with Left Bundle Branch Block (LBBB). Researchers found that LBBB patients had significantly higher dyssynchrony, larger heart chambers, and weaker pumping ability (ejection fraction) compared to controls. Crucially, the combination of uncoordinated timing and uneven blood flow between different heart walls (the septal-to-lateral ratio) predicted worse heart remodeling and lower function. Ultimately, the study concluded that the severity of timing and blood flow issues—not the LBBB diagnosis itself—independently predicted risks of death or heart failure. These markers offer a precise way to identify patients at higher risk for heart complications.
Moderate–severe ischaemia on nuclear myocardial perfusion imaging is not associated with mortality or MACCE after chronic total occlusion percutaneous coronary intervention
Henningsen JB, Søndergaard MM, Jørgensen SH, et al.
Impact of myocardial perfusion abnormalities on clinical outcomes in patients treated with percutaneous coronary intervention for chronic total occlusions.
Eur Heart J Imaging Methods Pract 2026; 4:qyaf137; https://doi.org/10.1093/ehjimp/qyaf137
The study aimed to evaluate the prognostic significance of myocardial perfusion imaging (MPI) in patients with chronic total occlusion (CTO) treated by percutaneous coronary intervention (PCI). It included patients from the Western Danish Heart Registry assessed by nuclear MPI, stratified by the presence of moderate–severe ischaemia (defined as ≥10% left ventricle involvement). Among 319 patients, 208 (65.2%) had moderate–severe ischaemia. All-cause mortality was similar between patients with and without moderate–severe ischaemia [adjusted hazard ratio (aHR) 1.12, 95% confidence interval (CI): 0.52–2.43], P = 0.77). The estimated risk of MACCE (cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure or angina pectoris) was comparable between groups at 90 days [aHR 0.76 (0.38–1.55), P = 0.46] and 5 years [aHR 0.74 (0.45–1.20), P = 0.22]. Hospitalization for angina was even decreased after 5 years in patients with moderate–severe ischaemia [aHR 0.46 (0.23–0.91), P = 0.026]. The Authors concluded that moderate–severe ischaemia on nuclear MPI was not associated with differences in mortality or MACCE after CTO-PCI, and associated with a lower long-term risk of angina hospitalization.
Keywords: nuclear imaging; myocardial perfusion; coronary artery disease; prognosis; chronic total occlusion; percutaneous coronary intervention.
Lay summary: This study investigated whether the amount of heart muscle lacking oxygen (ischemia) predicts long-term health outcomes for patients undergoing percutaneous revascularization of totally occluded coronary artery (CTO). Researchers followed 319 patients, comparing those with significant ischemia (at least 10% of the heart affected) to those with milder cases. Surprisingly, after five years, patients with more severe ischemia did not have a higher risk of death, heart attacks, or strokes compared to the milder group. In fact, the group with more severe ischemia actually had a slightly lower risk of being hospitalized for chest pain (angina) over the long term.