Echocardiography
Funnel-shaped PFO on 3D TEE: a marker of higher cerebrovascular risk
Totaro A, Sacra C, Testa G, et al.
Funnel-type patent foramen ovale morphology on 3D echocardiography: a novel high risk anatomic feature
Eur Heart J Cardiovasc Imaging 2026; 27:1300-1314; https://doi.org/10.1093/ehjci/jeag089
This retrospective single-centre study assessed whether 3D TEE can improve risk stratification in patients with patent foramen ovale (PFO) and right-to-left shunt. Ninety-five patients underwent 3D TEE, with PFO morphology classified by internal tunnel geometry as funnel type, with a wider right atrial (RA) opening, or cone type, with a wider left atrial opening. This morphology was analysed in relation to previous ischaemic stroke or transient ischaemic attack. Prior events were present in 37 patients (38.9%). Compared with patients without events, those with prior events had a larger RA opening area (48.5 [18.4–67.0] vs. 11.75 [8.6–17.9] mm²; P = 0.002). Funnel-type morphology was more frequent in the event group (81.1% vs. 50%; P = 0.001) and was associated with more than a two-fold higher event rate than cone type (50.8% vs. 19.4%; P = 0.002). In multivariable analysis, dyslipidaemia, smoking, funnel morphology, and larger RA opening area independently predicted prior events. ROC analysis identified an RA opening area >15.85 mm² as the optimal threshold with an AUC of 0.719. The Authors conclude that 3D TEE-defined funnel morphology may identify a higher-risk PFO phenotype. Combining this anatomy with clinical risk factors may improve PFO risk stratification and management.
Keywords: 3D echocardiography; transoesophageal echocardiography; patent foramen ovale; right-to-left shunt; stroke; transient ischaemic attack; PFO morphology.
Lay summary: A patent foramen ovale is a small opening between the heart’s upper chambers that persists after birth in some people. In selected patients, it may be linked to stroke, but deciding which openings are risky can be difficult. This study used detailed 3D ultrasound from the oesophagus to examine the shape of the opening in 95 patients. The researchers found that a “funnel-shaped” PFO, with a wider opening on the right side of the heart, was more common in patients who had previously had a stroke or transient ischaemic attack. A larger right-sided opening was also linked with previous events. These findings may help doctors better identify patients who need closer assessment or possible closure of the PFO, but larger future studies are needed before this approach can guide routine decisions.
Women develop earlier LV remodelling in moderate aortic stenosis
Panaou K, Venema CS, van Bergeijk KH, et al.
Left Ventricular Changes in Moderate Aortic Stenosis in Women Compared to Men
Eur Heart J - Imaging Methods and Practice 2026; 4:qyag064; https://doi.org/10.1093/ehjimp/qyag064
This retrospective longitudinal cohort study evaluated sex differences in echocardiographic progression and LV adaptation in patients with asymptomatic moderate aortic stenosis. The authors analysed serial echocardiographic and clinical data from 542 patients, including 205 women and 337 men, with a median follow-up of 6.47 years. During AS progression, women showed higher LVEF, lower LV mass index, greater relative wall thickness, and more frequent diastolic dysfunction than men. While the overall prevalence and incidence of concentric hypertrophy were similar between sexes, women reached concentric hypertrophy and diastolic dysfunction at lower mean gradients. Although symptom incidence and timing were similar, symptomatic women presented with dyspnoea more often than men (87.8% vs. 74.8%; P = 0.021). Time to aortic valve replacement and mortality did not differ by sex. The study suggests that women with moderate AS may experience LV structural and functional changes at an earlier stenosis severity stage than men, underscoring the value of sex-aware echocardiographic interpretation during follow-up.
Keywords: transthoracic echocardiography; aortic stenosis; sex differences; left ventricular remodelling; concentric hypertrophy; diastolic dysfunction.
Lay summary: This study looked at whether women and men with moderate narrowing of the aortic valve develop different changes in the heart muscle over time. The researchers followed 542 patients using repeated heart ultrasound scans. They found that women developed thickening and stiffness of the left ventricle of the heart at lower levels of valve narrowing than men. Women who developed symptoms were also more likely to report breathlessness. However, the overall timing of symptoms, valve replacement, and death was similar between women and men. These results suggest that doctors may need to pay close attention to early heart muscle changes in women with moderate aortic valve narrowing.
Evaluation of diastolic function: machine learning improves classification of left ventricular filling pressure
Khan FH, Inoue K, Ohte N, et al.
Evaluation of diastolic function: machine learning improves classification of left ventricular filling pressure.
Eur Heart J Cardiovasc Imaging 2026; 27:1205-1212; https://doi.org/10.1093/ehjci/jeag025
This multicentre study aimed to develop and validate the machine learning (ML) models for classifying left ventricular filling pressure (LVFP). The study included 250 patients who had performed invasive heart catheterization and echocardiography within 24 hours. Echocardiographic and clinical data was used for training and testing sets using a nested cross-validation procedure to classify LVFP as normal or elevated, using invasively measured pressure as a reference. The study also compared ML models to echocardiographic guideline algorithms for diastolic function. Results indicated that ML models could classify LVFP with accuracy ranging from 82% to 86%, while accuracy of 2016 ASE/EACVI guidelines algorithm was 81%, and of 2022 EACVI guidelines 78%. A main advantage of the ML models was that all patients could be classified, while this was not possible in 3-13% using guidelines algorithm due to missing parameters. The five highest ranked parameters by the ML models were mitral E/left atrial reservoir strain, NT-proBNP, tricuspid regurgitation velocity, septal E/e’, and E/A. The study concludes that ML models had comparable accuracy to the expert derived algorithm but had superior feasibility and left no patients unclassified, therefore, ML models could improve classification of LVFP.
Keywords: echocardiography, artificial intelligence, machine learning, diastolic function, left ventricular filling pressure
Lay summary: This study tested whether artificial intelligence, using machine learning models could help doctors better assess pressure inside the heart, called left ventricular filling pressure. In this study, 250 patients who had both echocardiography and invasive heart pressure measurements within 24 hours. The machine learning models were about as accurate as current expert guideline methods, correctly classifying patients in 82% to 86% of cases. However, an important advantage of machine learning models was the ability to classify also patient who lacked some echocardiographic measurements. The study suggests that machine learning may support doctors by making heart pressure assessment more practical, complete, and reliable in everyday care.
Bicuspid Aortic Valve in Infants without Severe Congenital Heart Defects: Early Echocardiographic Findings Guide Surveillance Strategies
Sherburne H, Kanade R, Johnson JN, et al.
Bicuspid Aortic Valve in Infants without Severe Congenital Heart Defects: Early Echocardiographic Findings Guide Surveillance Strategies.
J Am Soc Echocardiogr 2026; 39:581-591; https://doi.org/10.1016/j.echo.2026.02.006
This study aimed to elucidate the clinical features and outcomes of infants diagnosed with bicuspid aortic valve (BAV), particularly those without other complex congenital heart defects. The study included 103 infants diagnosed with BAV from 2001 to 2019 from Mayo Clinic echocardiography database. None of the 61 infants with normally functioning BAV at the time of initial echocardiogram required any aortic valve interventions at a median follow-up age of 6.0 years (IQR, 2.1-10.8 years). Among 35 infants with concomitant aortopathy at their first echocardiogram, none required intervention on the aorta at a median age of 8.8 years (IQR, 4.0-14.2 years), while 28 infants who had aortic stenosis on their first echocardiogram, 8 (29%) required valvular intervention by a median age of 12.4 years (IQR, 7.2-17.7 years). Presence of aortic stenosis on the initial echocardiogram was predictive of progression of aortic regurgitation (P = .007) and ascending aortic dilation (P = .0002). Authors concluded that Infants with normally functioning BAV did not develop significant valvulopathy or aortopathy over the first few years of life and required no interventions. While those with more than mild AS or ascending aortic dilation at first echocardiogram incurred higher risk of valvulopathy and aortopathy progression.
Keywords: echocardiography, bicuspid aortic valve, congenital heart disease, infants, outcome
Lay summary: This study analysed infants diagnosed with bicuspid aortic valve, a condition where the aortic valve has two leaflets instead of the usual three. Researchers wanted to understand which infants are likely to develop significant progression of disease and need closer follow-up and which may safely need fewer tests. They reviewed 103 infants diagnosed by echocardiography over an 18-year period. Infant whose valve was working normally at the first scan did very well, none needed valve treatment during six years follow-up. Infants who already had enlargement of the aorta also did not need aortic surgery. However, infants who had narrowing of the aortic valve at the first scan were more likely to have worsening valve leakage or enlargement of the aorta later, and some needed valve procedures.
Cardiovascular imaging for the evaluation and management of athletes: a clinical consensus statement of the European Association of Preventive Cardiology (EAPC) and the European Association of Cardiovascular Imaging (EACVI)
D’Ascenzi F, Sanz-de la Garza M, Maestrini V, et al.
Indications, protocols, and interpretation of cardiovascular imaging for the evaluation and management of athletes: a clinical consensus statement of the EAPC and EACVI of the ESC: Part 1
Eur Heart J – Cardiovascular Imaging 2026; jeag130; https://doi.org/10.1093/ehjci/jeag130
This EAPC/EACVI consensus statement provides a comprehensive framework for cardiovascular imaging in athletes. The core principle is that exercise imaging should be interpreted based on change from rest rather than absolute peak values, since athletes have lower resting ejection fraction due to chamber enlargement.
Exercise stress echocardiography (ESE) is the leading imaging modality, with images acquired at baseline, at each increment, and recovery. LV reserve: Failure to increase LVEF ≥11% from baseline, or peak LVEF <63%, distinguishes DCM from physiological dilatation (sensitivity ~80%, specificity ~96%). GLS increase <2% during exercise favours cardiomyopathy over athlete’s heart. RV reserve: Healthy athletes show normalisation or improvement of RV function during exercise. Atrial functional reserve: Impaired LA reserve during exercise may be an early marker of paroxysmal AF and atrial cardiomyopathy, before resting enlargement develops. In patients with mitral regurgitation, early sPAP rise >15 mmHg at first exercise stage predicts adverse events; in aortic stenosis, gradient increase >18–20 mmHg or LVEF drop <50% identifies high risk.
Nuclear imaging: exercise (not pharmacological) stress is mandatory for coronary anomaly evaluation. Stress-first SPECT reduces radiation by 50%. PET offers superior sensitivity.
Exercise CMR: superior for RV volumetry; best used when RV assessment is primary (arrhythmogenic cardiomyopathy, pulmonary hypertension, congenital heart disease).
Cardiopulmonary-ESE combined: most useful in HCM and valvular disease, simultaneously assessing dynamic LVOTO, VO2peak, and ventilatory thresholds for safe exercise prescription.
Keywords: exercise imaging, athletes, echocardiography, stress echocardiography, cardiac MRI, nuclear imaging, CPET, LV reserve, RV reserve, athlete’s heart, cardiomyopathy, valvular heart disease, HCM, ACM
Lay summary: This consensus statement by the EAPC and EACVI establishes standards for how cardiovascular imaging should be used in athletes. Rather than relying on absolute peak values, clinicians are guided to assess the change from rest during exercise, the “cardiac reserve”, as athletes naturally have larger hearts with lower resting function. The document covers all major imaging modalities (echocardiography, CMR, nuclear imaging) and their specific roles in diagnosing conditions such as cardiomyopathies, valvular disease, and coronary anomalies in the athletic population, and provides thresholds to guide clinical decision-making and safe exercise prescription.
Right ventricular longitudinal function is associated with exercise capacity in precapillary pulmonary hypertension
Jumatate R, Labaf A, Ingvarsson A, et al.
Right ventricular longitudinal function is associated with exercise capacity in precapillary pulmonary hypertension: a multimodality imaging study
Eur Heart J - Imaging Methods and Practice 2026; qyag116; https://doi.org/10.1093/ehjimp/qyag116
Right ventricular (RV) failure is a key determinant of outcome in precapillary pulmonary hypertension (PHprecap). Contemporary four-strata risk assessment incorporates functional capacity and NT-proBNP, yet the relationship between these and RV function remains unclear.
Patients with PHprecap (n=49; 69% women, median age 62 [IQR 52,74] years) underwent six-minute walk distance (6MWD), NT-proBNP sampling, right heart catheterization, and comprehensive RV assessment by echocardiography and cardiac magnetic resonance. In multivariable analysis adjusted for age and sex, 6MWD was associated with RV longitudinal function parameters (adjusted R2=0.33-0.50, all p<0.05), including FWS (B=-15.2, 95% CI -22.3 to -8; p < 0.001) and TAPSE/sPAP (B=338,6 95% CI 179.7-498.7; p < 0.001). In univariable analysis, log10(NT-proBNP) was associated with TAPSE, RV–PA coupling parameters, atrioventricular plane displacement, and CMR-derived FWS (all p <0.05), but only TAPSE/sPAP, S′/sPAP, and CMR-FWS remained significant after adjustment for mean right atrial pressure. Combined models showed minimal incremental explanatory value of RV function for 6MWD, whereas atrioventricular plane displacement and age were the only independent predictors (adjusted R2 ≈ 0.50).
Impaired RV longitudinal function is significantly associated with exercise capacity, regardless of imaging modality and confounders, whereas NT-proBNP provides a moderate reflection of right-sided filling pressures. Resting RV assessment may underestimate disease severity, and stress-based evaluation could better capture functional impairment in PHprecap.
Keywords: echocardiography, CMR, pulmonary hypertension, right ventricle
Lay summary: When the right heart fails in pulmonary hypertension, patients deteriorate, but it's unclear how well the standard clinical tests (a walking test and a blood marker) actually reflect right heart function. The authors studied 49 patients with same-day imaging, catheter measurements, and clinical tests to find out. How far patients could walk was strongly linked to how well the right heart muscle was contracting, regardless of imaging method used. The blood marker (NT-proBNP) reflected filling pressures more than pump function itself. Crucially, resting measurements may underestimate true disease severity, while assessing the heart during exercise could better capture how impaired patients really are.
CMR
In type-2 diabetes mellitus, abnormal myocardial perfusion reserve and myocardial infarction are associated with major adverse events
Sharrack N, Knott KD, Yeo JL et al.
Abnormal myocardial perfusion reserve and myocardial infarction determine cardiovascular outcomes in type 2 diabetes mellitus
Eur Heart J Cardiovasc Imaging 2026; 27:984-995; https://doi.org/10.1093/ehjci/jeag047
This study investigated whether abnormal myocardial perfusion reserve (MPR) and myocardial infarction (MI), assessed with cardiovascular magnetic resonance (CMR), are associated with worse outcomes in patients with type 2 diabetes mellitus (T2DM). A total of 572 patients with T2DM and 52 healthy controls underwent stress quantitative perfusion CMR and late gadolinium enhancement (LGE). Patients were classified as: no MI and normal MPR (n=261), either MI or abnormal MPR (n=223), or both MI and abnormal MPR (n=88); abnormal MPR was defined as <1.91. Over a median of 28 months, 14% of patients experienced at least one major adverse cardiovascular or cerebrovascular event (death, MI, stroke, heart failure hospitalization, or late revascularization). Event rates increased stepwise across the three groups (8%, 15%, and 30%; p<0.001), and in multivariable analyses both reduced MPR and MI were independently associated with a worse prognosis, with the combination yielding the highest risk (HR 3.24, CI 1.75–6.01). The Authors concluded that global MPR and LGE‑defined MI offer complementary prognostic information in T2DM, supporting combined quantitative perfusion and scar imaging for refined risk stratification. However, routine screening for silent coronary disease in asymptomatic diabetes remains controversial and further prospective studies are needed.
Keywords: cardiovascular magnetic resonance; quantitative perfusion mapping; myocardial perfusion reserve; type 2 diabetes mellitus; myocardial infarction; prognosis; coronary microvascular dysfunction
Lay summary: This study looked at whether an advanced heart MRI scan can identify people with type 2 diabetes who are at higher risk of heart attacks, strokes, or heart failure. The scan measures how well blood flow to the heart muscle increases under stress (called myocardial perfusion reserve) and also detects small or “silent” heart attacks. During a 2-year follow-up, patients with both poor blood‑flow reserve and prior infarction had the highest chance of serious cardiovascular events. Patients with normal blood‑flow reserve and no scar had the lowest risk. These findings suggest that this type of MRI could help more accurately identify high‑risk patients with diabetes, but larger studies are needed before it can be recommended as a routine screening test.
Myocardial tissue injury stages in ST-elevation myocardial infarction using the Canadian Cardiovascular Society classification
Lechner I, Carberry J, Stiermaier T et al.
Associations and prognostic implications of myocardial tissue injury stages in ST-elevation myocardial infarction using the Canadian Cardiovascular Society classification
Eur Heart J Cardiovasc Imaging 2026; 27:638-649; https://doi.org/10.1093/ehjci/jeaf250
This study assessed whether the Canadian Cardiovascular Society (CSS) endorsed classification of CMR‑based tissue‑injury stages in reperfused STEMI has a prognostic value and relates to clinical, imaging, and biomarkers. In 1,109 PCI‑treated STEMI patients from three prospective cohorts (HEM CMR, BHF MR MI, MARINA STEMI) undergoing CMR about 3 days after infarction, were classified into: Stage 1 (aborted myocardial infarction), Stage 2 (necrosis without microvascular obstruction [MVO]),), Stage 3 (necrosis with MVO but no intramyocardial haemorrhage [IMH]), and Stage 4 (necrosis with IMH). Stage‑1 patients had small infarcts, preserved LV function, lower biomarker release and <1% 1‑year MACE (defined as all-cause death or new-onset heart failure—and all-cause mortality alone at 12 months), whereas Stage‑4 patients had the largest infarcts (median infarct size of 27%), most adverse remodelling and a ~16% 1‑year MACE rate. In contrast, Stages 2 and 3 showed similar MACE and mortality, despite differences in MVO. Overall, the CSS CMR based STEMI classification remained an independent prognostic predictor beyond clinical risk scores and global left ventricular measures.
Keywords: ST-segment elevation myocardial infarction; cardiac magnetic resonance; microvascular injury; prognosis.
Lay summary: This study used advanced heart CMR analysis to see how different “tissue‑injury stages” after a major heart attack relate to patient’s future risk. All patients had a scan to show how much heart muscle was damaged, whether small vessels were blocked, and whether bleeding into the heart muscle occurred. Patients with almost no permanent damage did very well over the following year, with almost no serious events. Those with large infarcts and bleeding inside the heart muscle had much worse outcomes, including more heart failure and deaths. People in the middle categories, with moderate damage with or without small‑vessel blockage, had similar intermediate risks. These findings suggest that CMR ‑based stages can help doctors identify very low‑ and very high‑risk patients after a heart attack; the middle stages need to be refined to better distinguish risk.
Myocardial Amyloid Burden in Transthyretin Amyloidosis
Sheikh A, Achten A, Aimo A, et al.
Myocardial Amyloid Burden in Transthyretin Amyloidosis
J Am Coll Cardiol 2026; 87:505-518; https://doi.org/10.1016/j.jacc.2025.10.054
This study aimed to define cardiovascular magnetic resonance (CMR) extracellular volume (ECV) thresholds for quantifying myocardial amyloid burden in transthyretin amyloidosis (ATTR), and to assess their diagnostic and prognostic value. A total of 1,541 subjects undergoing CMR for ATTR were studied, including TTR variant carriers, patients with extracardiac ATTR, early-stage ATTR cardiomyopathy (ATTR-CM), and overt ATTR-CM. The primary endpoint was all-cause mortality.
ECV increased progressively from early-stage disease to overt ATTR-CM. Diagnostic performance was excellent: ECV <30% excluded cardiac involvement, ECV ≥40% confirmed cardiac involvement, while values of 30%-39% indicated early myocardial infiltration. Over a median follow-up of 2.8 years, 612 patients (40%) died. Increasing ECV-defined amyloid burden—none (<30%), mild (30%-39%), moderate (40%-49%), moderate-to-severe (50%-59%), and severe (≥60%)—was associated with a progressive increase in mortality risk. Importantly, ECV retained prognostic value across biomarker levels, Perugini grades, and LV mass index strata.
CMR-derived ECV directly quantifies myocardial amyloid burden and provides reproducible thresholds for diagnosis and prognosis. These findings also provide a quantitative framework for therapeutic planning, particularly as emerging treatments aim not only to prevent new amyloid formation but also to clear existing myocardial deposits.
Keywords: cardiovascular magnetic resonance; Extracellular volume; Myocardial amyloid burden; Risk prediction; Transthyretin amyloidosis
Lay summary: This large study looked at whether cardiac MRI can measure how much amyloid protein has accumulated in the heart in people with transthyretin amyloidosis. The researchers found that a cardiac MRI measure called extracellular volume (ECV) could reliably quantify the amount of amyloid in the heart. An ECV below 30% generally excluded heart involvement, values of 30%-39% suggested early infiltration, and values of 40% or higher confirmed cardiac involvement. Higher ECV values were associated with progressively worse survival. These findings suggest that ECV could help doctors detect heart involvement earlier, measure disease severity, predict prognosis, and potentially guide future treatments designed to remove existing amyloid deposits from the heart.
Withdrawal of heart failure therapy after atrial fibrillation rhythm control with ejection fraction normalization: the WITHDRAW-AF trial
Segan L, Kistler PM, Nanayakkara S, et al.
Withdrawal of heart failure therapy after atrial fibrillation rhythm control with ejection fraction normalization: the WITHDRAW-AF trial
Eur Heart J 2026; 47:250-262; https://doi.org/10.1093/eurheartj/ehaf563
This randomized multicentre trial investigated whether heart failure (HF) therapy can be safely withdrawn in patients with atrial fibrillation-mediated cardiomyopathy (AFCM) after successful rhythm control and normalization of left ventricular ejection fraction (LVEF). Sixty patients were randomized to early withdrawal of HF therapy or continued therapy for 6 months followed by delayed withdrawal, using a crossover design. Catheter ablation had been performed in 97% of participants. At 6 months, LVEF ≥50% was maintained in 90% of patients undergoing HF therapy withdrawal compared with 100% of those continuing therapy (p=0.479. CMR-derived LVEF was similar between groups at the end of the randomized phase (58% vs 59%; p=0.236) and remained comparable across study time points. Echocardiographic measures, NT-proBNP, functional status, quality of life, and AF burden were also similar on vs off HF therapy.
These findings suggest that indefinite HF pharmacotherapy may not be necessary for all patients with apparently reversible AF-mediated cardiomyopathy, although careful patient selection and ongoing rhythm and ventricular function surveillance remain important.
Keywords: AF-mediated cardiomyopathy; Arrhythmia-induced cardiomyopathy; Atrial fibrillation; Catheter ablation; Heart failure therapy; Recovered ejection fraction; Rhythm control
Lay summary: This study examined whether people whose heart function had recovered after successful treatment of atrial fibrillation could safely stop their heart failure medications. Most participants had undergone AF ablation and had maintained a normal heart rhythm for at least 6 months. After heart failure medications were gradually withdrawn, 90% maintained normal heart pumping function at 6 months, compared with 100% of those who continued treatment, with no significant differences in heart function, symptoms, biomarkers, quality of life, or AF burden. The findings suggest that some carefully selected patients whose weakened heart was primarily caused by atrial fibrillation may be able to stop heart failure medication after successful rhythm control and recovery of heart function, provided they remain closely monitored.
Increased ECV is an independent prognostic predictor in hypertrophic cardiomyopathy
Lee HJ, Gwak SY, Lee S, et al.
Enhanced risk stratification in hypertrophic cardiomyopathy through the integration of extracellular volume fraction on cardiovascular magnetic resonance
Eur Heart J Cardiovasc Imaging 2026; jeag146; https://doi.org/10.1093/ehjci/jeag146
This study investigated the incremental prognostic value of extracellular volume fraction (ECV) in 990 patients with hypertrophic cardiomyopathy (HCM) on top of late gadolinium enhancement (LGE). During a median follow-up of 3.2 years, 64 (6.5%) patients experienced the primary endpoint (including sudden death and heart failure events). While LGE (median 7.1%, IQR 2.3-16.9%) and ECV (median 29.0%, IQR 26.6-32.0%) were moderately correlated (R = 0.604, P < 0.001), both were significantly associated with increased risk, and optimal cutoffs were determined as LGE ≥ 27% and ECV ≥ 35%. Patients with ECV ≥ 35% had more symptoms, a more severe phenotype with greater systolic and diastolic dysfunction, and more pathogenic gene variants. Notably, ECV remained a significant predictor of the primary endpoint (adjusted HR 1.08, 95% CI 1.02-1.15, per 1%) after adjustment for key disease variables, including left ventricular ejection fraction and LGE. Elevated ECV effectively identified high-risk individuals even among lower-risk subgroups, including those with low LGE burden. In conclusion, increased ECV is an independent predictor of adverse events and refines risk stratification on top of traditional imaging criteria.
Keywords: cardiovascular magnetic resonance; extracellular volume fraction; hypertrophic cardiomyopathy; magnetic resonance imaging; myocardial fibrosis
Lay summary: This study investigated the prognostic role of extracellular volume fraction (ECV) in 990 hypertrophic cardiomyopathy (HCM) patients undergoing cardiac magnetic resonance (CMR). Elevated ECV independently predicted adverse events over 3.2 years, even when accounting for traditional CMR parameters including late gadolinium enhancement (LGE). Patients with an ECV of 35% or higher displayed more severe disease, and the measurement helped identify high-risk individuals, including those with low LGE burden.
Longitudinal T1 mapping and T2* changes for assessing myocardial iron overload
Meloni A, Pistoia L, Positano V, et al.
Longitudinal Assessment of Cardiac Native T1 in Transfusion-Dependent Thalassemia
Rev Cardiovasc Med 2026; 27:50439; https://doi.org/10.31083/RCM50439
Cardiovascular magnetic resonance (CMR) T2* is the reference standard for assessing myocardial iron overload (MIO). Native T1 mapping has emerged as a complementary technique and may be more sensitive for detecting mild or early myocardial iron deposition. In this study, 64 patients with transfusion-dependent thalassemia (TDT) underwent two 1.5T CMR scans. At baseline, mean LV T1 was 959.51 ± 101.46 ms and mean LV T2* was 37.17 ± 9.44 ms, with a significant correlation between the two parameters (R = 0.533; p < 0.0001). After 18-month follow-up, global LV T1 did not change significantly (mean change 1.99 ± 63.57 ms; p = 0.841), whereas LV T2* increased significantly (mean change 1.61 ± 4.52 ms; p = 0.001). Individual T1 trajectories varied: 22.2% of patients with normal baseline T1 developed reduced T1, while 26.9% of those with reduced baseline T1 normalized at follow-up. Changes in LV T1 were inversely associated with baseline T1 values (R = -0.406, p = 0.001) and correlated with changes in T2* (R = 0.311, p = 0.012), but not with age, ferritin, haemoglobin levels, or LV ejection fraction. In conclusion, native T1 mapping represents a complementary, but not interchangeable, tool to T2* for the assessment and longitudinal monitoring of MIO.
Keywords: cardiovascular magnetic resonance; iron overload; thalassemia; T1 mapping; T2*
Lay summary: Patients with thalassemia who receive frequent blood transfusions risk a dangerous buildup of iron in the heart, which is monitored using MRI scans. This study showed that using the standard test (called T2*) alongside a newer technique (called T1 mapping) provides a much clearer picture. The two methods track iron changes slightly differently. While the standard test showed general improvement across the group over 18 months, the new mapping technique revealed that individual patient patterns varied greatly. This proves that combining both tests gives doctors a more precise way to catch early iron buildup and monitor heart health over time.
Cardiac CT
The prognostic value of the CCTA derived segment involvement score, coronary artery stenosis severity and CAC score in everyday real world clinical practice according to the Swedish registry
Henrik Löfmark, Ellen Ostenfeld, Tomasz Baron, et al.
Computed tomography derived segment involvement score and coronary artery calcium score when used in clinical routine—data from a Swedish Registry Cohort
Eur Heart J - Cardiovasc Imaging 2026; 27:1345-1354; https://doi.org/10.1093/ehjci/jeag090
This study aimed to evaluate the prognostic value of segment involvement score (SIS) from coronary computed tomography angiography (CCTA) and compare it with calcium score (CACS) in real world clinical practice. The study included 23,034 patients with suspected coronary artery disease who had a CCTA at one of the 27 centres in Sweden who participated in the study. The patients were followed-up for a median period of 2.5years and the end-point was all-cause death and/or myocardial infarction (MI). SIS=0 was found in 61.4%. SIS ≥ 4 was independently associated higher risk of death (HR 1.39), MI (3.53) and death/MI (1.88) compared to SIS 0. Obstructive stenosis (≥50%) was also independently associated with all outcomes but showed lower discrimination than SIS in receiver operating characteristic curve (ROC) analyses. SIS and CACS had similar ability to predict death /MI and MI alone, in ROC analysis, while CACS performed better than SIS in predicting death. This study demonstrated that the extend of coronary atherosclerosis as defined by SIS (≥4) and the presence of obstructive coronary disease (≥50%) are independently associated with the long-term outcome. However, they do not provide additional prognostic value over CACS.
Keywords: CT, CCTA, coronary artery disease, CAC score, SIS score, coronary obstructive disease, registry, long-term outcome
Lay summary: This study is based on a registry of patients who had clinically indicated CCTA in Sweden and demonstrated that SIS ≥ 4 was associated with 5-fold increased risk of MI and 3-fold increased risk of death compared with individuals without atherosclerosis. The extend of atherosclerosis, assessed by SIS, was a stronger predictor of outcomes than the presence of obstructive coronary artery disease (≥50%). However, when SIS was compared with CACS, the prognostic value was similar. This last conclusion, hast to be interpreted with caution, since the analysis was not performed in a core-lab and there was a substantial variability in the interpretation of CCTA when first implemented in Sweden. Additionally, recent studies applying AI on CCTA quantitative analysis demonstrated that the extend of atherosclerosis outperforms CAS prognostic value.
Prognostic value of the atherosclerosis detected on coronary CTA by AI-based quantification vs visual assessment; insights from the CONFIRM2 registry
van Rosendael A, Nakanishi R, Bax JJ, et al.
Prognostic Value of AI-Based Quantitative Coronary CTA vs Human Reader-Based Visual Assessment. Results From the CONFIRM2 Registry
J Am Coll Cardiol Img 2026; 19: 345–359; https://doi.org/10.1016/j.jcmg.2025.09.021
This study aimed to evaluate the prognostic value of AI-based quantitative coronary CTA (QCTA) versus human CTA reads, including the CAD-RADS and CACS score. The analysis was based on the CONFIRM2 registry, a multicentre, international cohort of clinically indicated CTAs. Asymptomatic and patients with established CAD were excluded. AI QCT evaluated the whole heart coronary plaque volume and stenosis, and two parameters were having the strongest predictive value, the diameter stenosis and the non-calcified plaque burden. The patients were followed-up for MACE and death/MI for a median of 3 years. In 1,916 patients studied for this analysis there was a stepwise risk increase with higher CAD-RADS and CACS. The addition of AI-QCT significantly improved risk stratification for MACE compared to CAD-RADS and CAD-RADS+CACS. AI-QCTA also improved discrimination when results were adjusted for the risk factor–weighted clinical likelihood (modified Duke index) and for the prediction of death/MI. After excluding 195 patients with severe stenosis (>70%), in a multivariable model of CAD-RADS and AI-QCTA, only AI-QCTA was significantly associated with MACE and death/ MI, and AI-QCTA significantly improved risk stratification compared with CAD-RADS for MACE (NRI: 0.54; P<0.001) and death/MI (NRI: 0.69; P=0.001). This study demonstrated that AI-QCTA significantly improved risk stratification over and above CAD-RADS and CACS in patients having clinically indicated CTA.
Keywords: AI, CT, CTA, CCTA, QCTA, coronary artery disease, atherosclerosis, plaque burden, CAC score, registry, long-term outcome
Lay summary: This study is based on the CONFIRM2 registry, on 1,916 patients referred for CTA: AI-guided whole heart coronary atherosclerosis quantification and its prognostic value was compared with the human-based CAD-RADS and CACS, scores applied in everyday clinical practice. The analysis demonstrated that AI-QCTA parameters of total noncalcified plaque burden and stenosis severity improved the risk stratification provided by the qualitative assessment of atherosclerosis by CAD-RADS, CACS and Duke index. The current analysis demonstrates that the degree of coronary artery stenosis has significant prognostic value assessed either qualitative (CAD-RADS) or quantitative (QCTA). The AI-QCTA assessment of noncalcified plaque burden improves risk stratification compared with the CAD-RADS / CACS. Special prognostic value of AI-QCTA in those with coronary artery diameter stenosis severity <70%.
Ability of artificial intelligence-based quantitative CT (AI-QCT) parameters, diameter stenosis, percent atheroma volume and average lumen area to rule-in or rule-out ischaemia
Kamila PA, Nurmohamed NS, Danad I, et al.
Artificial intelligence-guided quantitative coronary CT assessment to rule-in or rule-out myocardial ischaemia
Eur Heart J Cardiovasc Imaging 2026; 27:1192–1204; https://doi.org/10.1093/ehjci/jeag094
This study evaluated whether artificial intelligence (AI)-guided quantitative analysis of coronary CT angiography (CCTA) can improve the identification of myocardial ischaemia. This post-hoc, vessel-level analysis included patients with suspected coronary artery disease from the computed tomographic evaluation of atherosclerotic determinants of myocardial ischaemia (CREDENCE) (612 patients; 1727 vessels) and PACIFIC-1 (208 patients; 612 vessels) studies who underwent CCTA and invasive fractional flow reserve (FFR). In addition to diameter stenosis, percent atheroma volume (PAV) and average lumen area (ALA) were evaluated as key predictors of ischaemia. Results showed that AI-enhanced CT analysis including diameter stenosis, PAV (>14.7%), and ALA (<3.9 mm2) improved diagnostic performance compared with conventional anatomical assessment alone and may help both rule-in and rule-out myocardial ischaemia without requiring additional functional testing. This practical approach enhances the diagnostic utility of CCTA and streamlines clinical decision-making. The findings support the growing role of AI in transforming CCTA from a purely anatomical technique into a more comprehensive tool for functional risk assessment.
Keywords: Cardiac CT; coronary CT angiography; artificial intelligence; myocardial ischaemia; coronary artery disease; quantitative plaque analysis.
Lay summary: Researchers tested whether artificial intelligence can make heart CT scans more accurate in identifying patients whose coronary artery narrowing actually reduce blood flow to the heart muscle. By analysing CT images in greater detail than traditional methods, the AI system better distinguished patients with and without significant ischaemia. This approach could reduce the need for additional stress imaging tests and help clinicians make faster and more precise treatment decisions.
Adding a delayed phase to cardiac computed tomography for coronary artery evaluation provides prognostic information
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; 27: 969-980; https://doi.org/10.1093/ehjci/jeag018
This study investigated whether adding delayed-phase cardiac CT imaging to standard coronary CT angiography improves risk stratification in patients evaluated for coronary artery disease. Delayed imaging enabled assessment of extracellular volume (ECV), a marker of diffuse myocardial fibrosis, and late iodine enhancement (LIE), a marker of focal myocardial scar. In 1207 patients undergoing coronary CT angiography, LIE and elevated ECV provided incremental prognostic information beyond coronary anatomy during a mean 26.0 ± 19.1-month follow-up, with those having LIE and elevated ECV showing the highest cumulative incidence of composite events. The results suggest that a comprehensive cardiac CT protocol can simultaneously evaluate coronary disease, myocardial fibrosis, and scar burden, potentially improving cardiovascular risk prediction.
Keywords: Cardiac computed tomography; coronary artery disease; extracellular volume; late iodine enhancement; myocardial fibrosis; prognosis.
Lay summary: A standard cardiac CT scan is usually performed to look for blocked coronary arteries. In this study, researchers added a second scan a few minutes later to assess whether the heart muscle had fibrosis or scarring. They found that patients with more fibrosis or scar tissue had a higher risk of future cardiovascular events. This suggests that cardiac CT may provide information not only about coronary arteries but also about the health of the heart muscle itself, helping doctors identify higher-risk patients more accurately.
Photon-counting computed tomography: a revolution in cardiac imaging
Pontone G, Mushtaq S, Pizzi C, et al.
Photon-counting computed tomography: a revolution in cardiac imaging
Eur Heart J 2026; ehaf1118; https://doi.org/10.1093/eurheartj/ehaf1118
This state-of-the-art review examines the clinical impact of photon-counting detector CT (PCD-CT), a new generation of CT technology that directly converts X-ray photons into electrical signals. Compared with conventional energy-integrating detector CT, PCD-CT provides higher spatial resolution, improved contrast-to-noise ratio, superior spectral imaging capabilities, reduced blooming and beam-hardening artefacts, and the potential for lower radiation exposure. The technology appears particularly promising for the assessment of heavily calcified coronary arteries, coronary stents, plaque characterization, myocardial perfusion, extracellular volume quantification, and myocardial tissue characterization. The authors discuss how PCD-CT may expand the role of cardiac CT from coronary artery assessment to a comprehensive “one-stop-shop” evaluation of coronary anatomy, plaque biology, cardiac structure, and myocardial disease. While early clinical results are highly encouraging, larger prospective studies are still needed to establish its impact on clinical outcomes and cost-effectiveness.
Keywords: photon-counting CT; cardiac CT; coronary CT angiography; plaque characterization; coronary stents; myocardial tissue characterization; spectral imaging; cardiovascular imaging.
Lay summary: Cardiac CT scans are widely used to detect coronary artery disease, but image quality can be limited by calcium deposits, coronary stents, and image noise. Photon-counting CT is a new technology that captures X-ray information more efficiently and in greater detail than conventional CT scanners. This allows doctors to see coronary arteries more clearly, better identify dangerous plaque, assess stents more accurately, and potentially evaluate the heart muscle itself during the same examination. The technology may transform cardiac CT into a comprehensive test that provides both anatomical and tissue information, helping clinicians make more precise diagnoses while potentially reducing radiation exposure. Further studies are needed before widespread adoption in routine clinical practice.
In patients with atrial fibrillation, electroanatomical mapping and computed tomography provide complementary information on left atrial geometry
Moriones L, Lamata P, Echebarria B, et al.
Left atrial geometry in atrial Fibrillation: A comparison between electroanatomical mapping and computed tomography
Eur J Radiol 2026; 203:113042; https://doi.org/10.1016/j.ejrad.2026.113042
In patients with atrial fibrillation (AF), computed tomography (CT) is the reference standard for anatomical assessment of the left atrium (LA), whereas electroanatomical mapping (EAM) provides electrophysiological information. In this retrospective study on 211 patients undergoing first-time catheter ablation with pre-procedural CT imaging, LA geometry (volume, surface area, and sphericity) was derived from CT and EAM. A common ellipsoidal model was fitted to both datasets for comparison via semi-axes (a, b, c). EAM correlated with CT for volume (r = 0.58), area (r = 0.56), and sphericity (r = 0.49) (all p < 0.001). Bland-Altman analysis demonstrated systematic overestimation of volume (11.1 cm3, 13.2 %) and surface area (8.9 cm2, 9.6 %), with slight underestimation of sphericity (-0.01). In conclusion, EAM provides a rapid intraprocedural approximation of LA geometry but does not fully reproduce CT-derived anatomy, supporting its role as a complementary rather than substitute modality.
Keywords: Atrial Fibrillation; Computed Tomography; Electroanatomical Mapping; Image Segmentation; Left Atrial Geometry.
Lay summary: When treating atrial fibrillation (an irregular heartbeat), doctors map the heart’s left atrium using two main tools. CT scans provide highly accurate, 3D structural images, while electroanatomical mapping (EAM) tracks electrical activity during surgery. This study analysed data from 211 patients to see how well EAM duplicates the heart's true shape compared to a CT scan. The researchers found that while EAM provides a helpful, rapid approximation during surgery, it consistently overestimates the heart chamber's volume by about 13% and its surface area by nearly 10%. It also slightly miscalculates the chamber's overall roundness. Because of these structural discrepancies, these technologies should be used together as complementary tools: CT scans for exact anatomy and EAM for real-time electrical guidance.
Nuclear cardiology
Inflammation and calcification of the carotid plaque, detected by PET/CT, identify patients at high risk of stroke and cardiovascular events
Shao X, Bregenzer CM, Wang J, et al.
Carotid plaque inflammation and calcification on somatostatin receptor PET/CT imaging predict stroke and major adverse cardiovascular events.
Eur Heart J Cardiovasc Imaging 2026; jeag110; https://doi.org/10.1093/ehjci/jeag110
This study evaluated whether combined molecular and structural positron emission tomography/computed tomography (PET/CT) imaging of carotid plaques improves the prediction of subsequent stroke and major adverse cardiovascular events (MACE). A total of 353 patients undergoing [68Ga]DOTA-TOC PET/CT targeting somatostatin receptors of activated plaque macrophages were retrospectively analysed and categorized according to the presence of carotid calcification (CT) and/or inflammation (PET). Over a median follow-up of 4.5 years, patients exhibiting both calcified plaques and PET uptake had the highest incidence of stroke (15%) and MACE (12%). This combined PET/CT profile remained an independent predictor of adverse outcomes after adjustment for clinical risk factors.
Keywords: PET; somatostatin receptor imaging; carotid artery; atherosclerosis; inflammation; stroke
Lay summary: This study used an advanced PET/CT scan to detect both inflammation and calcium buildup in the neck arteries. Patients with both findings had a much higher risk of stroke and heart problems in the future. This combined imaging approach may help doctors identify high-risk patients more accurately and guide the intensity of early medical treatment.
15O-water PET enables safe and quantitative myocardial perfusion assessment in complex congenital heart disease
Kettunen S, Paakkanen R, Ojala T, et al.
15O-water PET perfusion in complex congenital heart disease.
Eur Heart J Imaging Methods Pract 2026; 3:qyag033; https://doi.org/10.1093/ehjimp/qyag033
This report describes the feasibility and clinical utility of quantitative myocardial perfusion imaging using 15O-water positron emission tomography (PET) perfusion in patients with complex congenital heart disease (CHD). PET using 15O-water is considered the reference standard for perfusion imaging due to its optimal tracer kinetics. Thirteen CHD patients, including transposition of the great arteries, Tetralogy of Fallot, and univentricular heart, underwent adenosine-stress PET imaging to exclude ischemia. The technique was feasible in all cases, yielding diagnostic-quality studies without adverse events and requiring no sedation, even in paediatric patients. Radiation dose was exceptionally low (0.3–0.6 mSv for stress PET), supporting its safety even for repeated use. Quantitative results showed normal stress myocardial blood flow (MBF) in 12/13 patients. Only one patient, with a known transmural scar on cardiac magnetic resonance, exhibited reduced perfusion. These findings demonstrate that 15O-water PET provides a robust three-dimensional physiological assessment of myocardial perfusion in complex CHD, complementing anatomical imaging where hemodynamic significance is uncertain. This modality may play a key role in detecting ischemia and guiding clinical decision-making in this growing and aging patient population.
Keywords: Congenital heart disease; PET perfusion; 15O-water; myocardial perfusion imaging
Lay summary: In patients with complex congenital heart disease, coronary artery narrowing can be caused by heart surgeries or by coronary artery disease. It can be sometimes difficult to determine whether symptoms are caused by reduced blood flow or by heart defects. This study tested a PET scan using radioactive water, which can accurately measure heart’s blood flow. The scan was safe, required very little radiation, and worked well for all patients, including children. This method can help to better understand how blood actually flows in hearts with complex medical conditions.
Novel PET tracer detects cardiac involvement even in rare cardiac amyloidosis subtypes missed by conventional imaging
Clerc OF, Romero Pabón AJ, Cuddy SAM, et al.
Assessment of cardiac involvement in rare forms of amyloidosis using positron emission tomography/computed tomography with 124I-evuzamitide (124I-p5+14, AT-01).
J Nucl Cardiol 2026; 60:102707; https://doi.org/10.1016/j.nuclcard.2026.102707
This study evaluated the ability of the novel positron emission tomography (PET) radiotracer 124I-evuzamitide to detect cardiac involvement in rare forms of amyloidosis, where standard imaging is often inconclusive. Ten patients with rare amyloidosis (six with known cardiomyopathy and four without) and twelve controls underwent PET/CT imaging. All patients with known cardiomyopathy demonstrated clear myocardial tracer uptake, while controls showed none. Importantly, 3 of 4 patients without clinical or imaging evidence of cardiomyopathy had myocardial uptake, suggesting subclinical cardiac involvement undetected by echocardiography, cardiac magnetic resonance, or single photon emission tomography. These findings suggest that 124I-evuzamitide PET/CT may enable earlier and more sensitive detection of any cardiac amyloidosis than current diagnostic approaches. The results also highlight the potential of PET imaging to redefine cardiac amyloidosis detection thresholds and guide earlier therapeutic interventions.
Keywords: PET/CT; cardiac amyloidosis; molecular imaging; 124I-evuzamitide
Lay summary: This study tested a new PET scan tracer designed to detect amyloid deposits in the heart. Amyloidosis can damage the heart and result in heart failure, but its rare forms are often difficult to detect using standard imaging tests. Researchers found that the new PET method detected heart involvement in all patients with known disease and, also in some patients without other signs of heart disease. This suggests that the PET scan can detect disease earlier than other tests. Earlier detection could help doctors start treatment sooner and improve patient outcomes.
Serial amyloid SPECT/CT scan in patients at risk of cardiac amyloidosis
Lo Presti S, Darwish A, Popovic Z, et al.
Yield and predictors of conversion on serial amyloid nuclear SPECT/CT in at-risk populations for transthyretin cardiac amyloidosis
Eur Heart J - Imaging Methods Pract 2026; 4: qyag089; https://doi.org/10.1093/ehjimp/qyag089
This retrospective single-centre study assessed the yield of serial Tc-99m PYP/HMDP SPECT/CT imaging in 106 individuals at increased risk for transthyretin cardiac amyloidosis (ATTR-CA) who had an initially negative scan. Over a mean follow-up of 3.0 years (1087 ± 525 days), 14 patients (13.2%) developed new myocardial tracer uptake consistent with imaging conversion. Only 14% of conversions occurred within the second year, whereas most were observed between 3 and 5 years after the baseline study. Conventional echocardiographic parameters, including left ventricular wall thickness and ejection fraction, as well as absolute troponin and NT-proBNP values, did not significantly differ between converters and non-converters. However, a ≥30% increase in NT-proBNP was more frequent among patients who converted (71.4% vs. 38.1%, P = 0.018). The strongest predictor of conversion was the combined presence of carpal tunnel syndrome and lumbar spinal stenosis, observed in 28.6% of converters compared with 4.5% of non-converters (P = 0.01). This phenotype remained independently associated with conversion after adjustment for age and sex (adjusted HR 5.95, P = 0.019). These findings support risk-adapted surveillance with serial amyloid SPECT/CT and reinforce current recommendations for repeat imaging at 3–5-year intervals in selected high-risk populations.
Keywords: SPECT/CT; Tc-99m PYP; transthyretin cardiac amyloidosis; ATTR-CA; nuclear cardiology; cardiac amyloidosis; carpal tunnel syndrome; lumbar spinal stenosis; risk stratification
Lay summary: Researchers studied whether repeated nuclear heart scans can help detect early transthyretin cardiac amyloidosis, a condition caused by abnormal protein deposits in the heart, in people considered at increased risk for the disease who initially had normal scan results. During three years of follow-up, around one in eight patients developed new signs of amyloid deposits on repeat imaging. Standard heart ultrasound measurements and blood tests often did not identify those who would later develop abnormalities. However, people who had both carpal tunnel syndrome and spinal stenosis were much more likely to show evidence of disease progression. The results support tailoring follow-up strategies according to a patient’s risk profile rather than applying the same surveillance schedule to everyone.
Evaluation of adenosine-induced splenic switch-off in Tc-99m tetrofosmin myocardial perfusion studies as marker of stress adequacy
Alkandari NF, Bouzabar MM, AlDhafiri DA, et al.
Evaluation of adenosine-induced splenic switch-off in Tc-99m tetrofosmin myocardial perfusion studies as marker of stress adequacy by semiquantitative analysis of acquired single-photon emission computed tomography/computed tomography images
Nucl Med Commun 2026; https://doi.org/10.1097/MNM.0000000000002203
Splenic switch-off (SSO) occurs during adenosine pharmacological stress, suggesting an adequate effect of adenosine. This study evaluated the effect of SSO in adenosine stress 99mTc tetrofosmin myocardial perfusion imaging studies using semiquantitative analysis of computed tomography/computed tomography (SPECT/CT). In 17 adenosine SPECT/CT studies, the spleen/vertebra ratio decreased and the myocardium/vertebra ratio did not change significantly. Using the method outlined, especially the S/V ratio, evaluation of the SSO can be achieved from the acquired data, which shows promise as a marker for adequate effectiveness of adenosine stress in doubtful cases.
Keywords: single-photon emission computed tomography (SPECT); myocardial perfusion; adenosine; splenic switch off
Lay summary: This study tested a method to confirm the efficacy of pharmacological heart stress tests by measuring "splenic switch-off," where blood flow to the spleen decreases during adenosine infusion, using SPECT/CT scans. Analysing the spleen-to-spine radioactivity ratio provides a reliable, objective marker to determine if adenosine has induced sufficient stress, particularly in ambiguous cases.
Myocardial Perfusion and Fluorodeoxyglucose Uptake Patterns in Cardiac Sarcoidosis Stratified by Diagnostic Category and Systemic Involvement
Sykora D, Davison J, Tersalvi G, et al.
Myocardial Perfusion and Fluorodeoxyglucose Uptake Patterns in Cardiac Sarcoidosis Stratified by Diagnostic Category and Systemic Involvement
Circ J 2026; https://doi.org/10.1253/circj.CJ-26-0423
18F-FDG PET/CT patterns in cardiac sarcoidosis (CS) across diagnostic subgroups are incompletely characterized. Definite CS (DCS) requires endomyocardial biopsy confirmation whereas probable CS is diagnosed by extracardiac biopsy with clinical/imaging criteria. This study analysed 221 patients with definite DCS, probable CS with active extracardiac sarcoidosis (PCS-A), or probable CS without extracardiac involvement (PCS-N). Myocardial perfusion was assessed with 13N-NH3, myocardial activity with 18F-FDG-PET on a segmental basis. DCS exhibited more severe perfusion defects than PCS-A and PCS-N. FDG uptake was similar in DCS and PCS-A, but lower in PCS-N. Abnormalities predominated in the basal/mid-septum and apical cap. In conclusion, distinct PET patterns characterize CS diagnostic categories and support current diagnostic criteria.
Keywords: PET/CT; cardiac sarcoidosis; 18F-FDG; 13N-NH3
Lay summary: Cardiac sarcoidosis is a rare inflammatory disease where immune cells form lumps in the heart, making accurate imaging diagnosis essential. By analysing 221 patients, this study found that definite, biopsy-confirmed cases showed the most severe blood flow issues, while patterns differed across diagnostic subgroups. The results confirm that specific PET scan patterns, often appearing in the mid-septum and apex, align with and support current diagnostic criteria.