Comparison of left ventricular ejection fraction and volumes in heart failure by echocardiography, radionuclide ventriculography and cardiovascular magnetic resonance; are they interchangeable?

Free-Breathing Single-Beat Exercise CMR with Generative AI for Evaluation of Volumetric and Functional Cardiac Indices: A Reproducibility Study

BACKGROUND

Exercise CMR (Ex-CMR) can reveal pathophysiologies not evident at rest by quantifying biventricular volume and function during or immediately after exercise. However, achieving reproducible Ex-CMR measurements is challenging due to limited spatial and temporal resolution. This study aimed to develop and evaluate a free-breathing, high-spatiotemporal-resolution single-beat Ex-CMR cine enhanced by generative AI. We assessed image analysis reproducibility, scan-rescan reproducibility, and impact of the reader's experience in the analysis.

METHODS

Imaging was performed on a 3T CMR system using a free-breathing, highly accelerated, multi-slice, single-beat cine sequence (in-plane spatiotemporal resolution of 1.9 × 1.9mm² and 37 ms, respectively). High acceleration was achieved by combining compressed sensing reconstruction with a resolution-enhancement generative adversarial inline neural network (REGAIN). Ex-CMR was performed using a supine ergometer positioned immediately outside the magnet bore. Single-beat cine images were acquired at rest and immediately post-exercise. In a prospective study, the protocol was evaluated in 141 subjects. A structured image analysis workflow was implemented. Four expert readers, with or without prior training in single-beat Ex-CMR, independently rated all images for diagnostic and image quality. The subjective assessment used two 3-point Likert scales. Biventricular parameters were calculated. Inter- and intra-observer reproducibility were assessed. Fifteen healthy subjects were re-imaged one year later for scan-rescan reproducibility. Reproducibility was assessed using intraclass correlation coefficient (ICC), with agreement evaluated via Bland-Altman analysis, linear regression, and Pearson correlation.

RESULTS

Free-breathing, single-beat Ex-CMR cine enabled imaging of the beating heart within 30 ± 6seconds, with technically successful scans in 96% of subjects. Post-exercise single-beat cine images were assessed as diagnostic in 98%, 96%, 82%, and 65% of cases by four readers (ordered by descending years of Ex-CMR experience). Good image quality was reported in 74% to 80% of subjects. Biventricular parameters were successfully measured in all subjects, demonstrating good to excellent inter-observer reproducibility. Scan/re-scan reproducibility over 1 year, assessed by two independent readers, showed excellent inter-visit ICCs (0.96-1.0) and strong correlations (R² ≥ 0.92, p < 0.001 for LV; R² ≥ 0.95, p < 0.001 for RV).

CONCLUSION

Single-beat Ex-CMR enabled evaluation of biventricular volumetric and functional indices with excellent reproducibility.

Female endurance athletes: smaller hearts but similar relationship between ventricular size, fitness and fibrosis as male athletes

OBJECTIVES

Exercise-induced cardiac remodelling is well described in male athletes but incompletely understood in females. This study aimed to examine sex differences in cardiac structure, function and fibrosis relative to fitness and to determine reference ranges for 'normal' chamber size in a large cohort of healthy male and female highly trained endurance athletes.

METHODS

This multicentre international study used cardiac MRI and cardiopulmonary exercise testing (VO2peak) to assess sex-specific relationships between measures of biventricular chamber size, function, fibrosis and VO2peak.

RESULTS

Of the 364 endurance athletes included, 36.5% were female. Compared with males, female athletes achieved lower VO2peak (51 (40-57) vs 59 (41-65) mL/kg/min, p<0.001), had smaller absolute and body surface area (BSA)-indexed left and right end-diastolic volumes (LVEDV, respectively) but similar volumes when indexed to fat-free mass. Both sexes showed a strong association between LVEDV and VO2peak (r=0.60-0.66) and a similar coefficient describing the linear relationship between VO2peak and LVEDV (Females: VO2peak(mL/min)=12.1×LVEDV+963.9; males: VO2peak=15.3×LVEDV+806.8, p=0.100) and BSA-indexed LVEDV (females: VO2peak (mL/kg/min)=0.37×LVEDV/BSA+12.5; males: VO2peak=0.51×LVEDV/BSA-1.2, p=0.059). There was no difference between right ventricular (RV) measures and VO2peak; however, males had 3.8 times higher odds of reduced RV ejection fraction. Prevalent myocardial scar was similar for both female (14.2%) and male (19.9%) athletes (p=0.180).

CONCLUSIONS

Female and male athletes demonstrate similar cardiac remodelling relative to fitness and no sex difference in myocardial scar. The female athlete's heart can show profound adaptation, and previous assertions that female hearts have lesser capacity for remodelling should be reappraised.

Cardiac Magnetic Resonance Guidance for the Pathogenetic Definition of Cardiomyopathies

PURPOSE OF REVIEW

Pathogenetics is the study of genetics in disease pathogenesis. Many abnormal gene alleles have been identified in cardiomyopathies, but their clinical utility remains limited. This review aims to examine the integration of cardiac MRI (CMR) with genetic data to enhance early detection, prognostication, and treatment strategies for cardiomyopathies.

RECENT FINDINGS

CMR is the gold standard imaging modality for cardiomyopathy evaluation, capable of detecting subtle structural and functional changes throughout the disease course. When applied to patients with genetic mutations, with or without phenotypic expression, CMR aids in early diagnosis and risk stratification. Cardiomyopathies can be categorized into at least seven clinical groups based on morphology, function, and genetic associations: (1) Dilated cardiomyopathy (DCM), (2) Hypertrophic cardiomyopathy (HCM), (3) Restrictive cardiomyopathy, including transthyretin amyloidosis (ATTR-CM), iron overload, and Anderson-Fabry disease, (4) Arrhythmogenic cardiomyopathy (ACM), (5) Non-dilated left ventricular cardiomyopathy (NDLVC), (6) Peripartum cardiomyopathy, and (7) Muscular dystrophy-related cardiomyopathy. We have described left ventricular noncompaction (LVNC) as a morphological trait rather than a distinct cardiomyopathy. Emerging CMR and genetic data suggest an inflammatory component in DCM and ACM, with potential therapeutic implications for immunotherapy. Advanced CMR techniques, such as quantitative perfusion, can distinguish cardiomyopathies from ischemic heart disease and detect early microvascular dysfunction, particularly in ATTR-CM and HCM. Late gadolinium enhancement (LGE) and parametric mapping (T1 and extracellular volume [ECV]) further enhance early diagnosis, prognostication and treatment response by assessing fibrosis and myocardial composition. The integration of CMR and genetic insights improves our understanding of cardiomyopathy pathogenesis, aiding in early diagnosis and prognostic assessment. Future research should leverage artificial intelligence (AI) to analyze genetic and radiomic CMR features, including perfusion data, to establish a comprehensive pathogenetic framework. This approach could refine disease classification, identify novel therapeutic targets, and advance precision medicine in cardiomyopathy management.

Cardiac Function Evaluation in Healthy Volunteers and Patients with Implantable Cardioverter-Defibrillators using High-Bandwidth Spoiled Gradient-Echo Cine

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) cause banding artifacts around areas of B0 inhomogeneity in conventional steady-state free precession (SSFP) cine sequences. Alternatively, high-bandwidth gradient-echo (GRE) cine sequences can be used to minimize artifacts in the myocardium. In this study, we assessed the bias and interobserver variability in cardiac volumes and ejection fractions between GRE cines in acquired in the presence of ICDS and ground-truth SSFP cines (without ICDs present) in a population of healthy volunteers. Further, a small cohort of ICD patients were recruited and scanned to demonstrate clinical feasibility.

METHODS

High-bandwidth GRE cine was performed in eleven healthy volunteers with taped ICDs mimicking clinical implants. After the ICD was removed, ground-truth SSFP cine was performed. Two observers separately assessed image quality metrics and contoured the cine images to return cardiac volumes and ejection fractions. Nine patients with an ICD were also scanned with the GRE cine protocol before contrast administration; data was contoured by two observers and analyzed for interobserver agreement.

RESULTS

In the healthy volunteer dataset, no statistically significant differences were found when comparing volumes or ejection fractions between sequences (p > 0.05). Statistically significant differences were found when comparing RVEF (p = 0.009) and RVESV (p = 0.029) between observers, with no other significant interobserver differences. The interobserver variability of patient LVEF and RVEF data was 3-4%, with lower image quality metrics for patient scans than volunteer scans.

CONCLUSION

GRE cine imaging in healthy volunteers with taped ICDs demonstrated good agreement with SSFP cine, but increased interobserver variability. In patients, reducing the breath-hold duration caused a decrease in image quality, with GRE cine imaging in patients with ICDs demonstrating poorer image quality and greater interobserver variability than in healthy volunteer studies. Future work is needed to improve GRE cine image quality in patients with ICDs to reduce interobserver variability and improve clinical confidence.

Free-breathing, Highly Accelerated, Single-beat, Multisection Cardiac Cine MRI with Generative Artificial Intelligence

Purpose To develop and evaluate a free-breathing, highly accelerated, multisection, single-beat cine sequence for cardiac MRI. Materials and Methods This prospective study, conducted from July 2022 to December 2023, included participants with various cardiac conditions as well as healthy participants who were imaged using a 3-T MRI system. A single-beat sequence was implemented, collecting data for each section in one heartbeat. Images were acquired with an in-plane spatiotemporal resolution of 1.9 × 1.9 mm2 and 37 msec and reconstructed using resolution enhancement generative adversarial inline neural network (REGAIN), a deep learning model. Multibreath-hold k-space-segmented (4.2-fold acceleration) and free-breathing single-beat (14.8-fold acceleration) cine images were collected, both reconstructed with REGAIN. Left ventricular (LV) and right ventricular (RV) parameters between the two methods were evaluated with linear regression, Bland-Altman analysis, and Pearson correlation. Three expert cardiologists independently scored diagnostic and image quality. Scan and rescan reproducibility was evaluated in a subset of participants 1 year apart using the intraclass correlation coefficient (ICC). Results This study included 136 participants (mean age [SD], 54 years ± 15; 69 female, 67 male), 40 healthy and 96 with cardiac conditions. k-Space-segmented and single-beat scan times were 2.6 minutes ± 0.8 and 0.5 minute ± 0.1, respectively. Strong correlations (P < .001) were observed between k-space-segmented and single-beat cine parameters in both LV (r = 0.97-0.99) and RV (r = 0.89-0.98). Scan and rescan reproducibility of single-beat cine was excellent (ICC, 0.97-1.0). Agreement among readers was high, with 125 of 136 (92%) images consistently assessed as diagnostic and 133 of 136 (98%) consistently rated as having good image quality by all readers. Conclusion Free-breathing 30-second single-beat cardiac cine MRI yielded accurate biventricular measurements, reduced scan time, and maintained high diagnostic and image quality compared with conventional multibreath-hold k-space-segmented cine images. Keywords: MR-Imaging, Cardiac, Heart, Imaging Sequences, Comparative Studies, Technology Assessment Supplemental material is available for this article. © RSNA, 2025.

Sex-Specific Associations of Cardiovascular Risk Factors With Subclinical Cardiac Remodelling: A Magnetic Resonance Imaging Study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in women, yet sex-specific risk factor influences remain understudied. Cardiac magnetic resonance (CMR) imaging detects early remodelling via left ventricular mass-to-volume ratio (LVMV), a validated concentricity marker. This study examines sex differences in the association of cardiovascular (CV) risk factors, diet, and cardiac remodelling.

METHODS

We analyzed 622 age-matched adults (51% female, mean age 50.8 ± 9.5) from the Courtois Cardiovascular Signature Program. LVMV was defined as left ventricular (LV) systolic mass divided by end-diastolic volume. Alcohol and sugar intake was self-rated on a Likert scale. Mann-Whitney U and regression analyses assessed sex-specific associations between CV risk factors and LVMV.

RESULTS

Hypertension was present in 20.6% of men and 17.4% of women: diabetes in 9.8% and 6.0%. Men had higher triglycerides, alcohol/sugar intake, and LVMV (0.92 ± 0.20 vs 0.77 ± 0.18 g/mL). Hypertension correlated with higher LVMV in both sexes (men: ß = 0.099, P < 0.001; women: ß = 0.078, P < 0.05), whereas triglycerides (ß = 0.032, P < 0.05) and alcohol intake (H = 19.41, P < 0.0001) were male-specific predictors. In female patients, diabetes and sugar intake were significantly associated with LVMV (ß = 0.102, ß = 0.062, P < 0.05).

CONCLUSIONS

CV risk factors affect cardiac remodelling differently by sex. In men, LVMV was linked to triglycerides and alcohol intake, whereas in women, diabetes and sugar intake showed stronger associations. These results underscore the need for tailored CV prevention strategies that account for sex differences in metabolic and lifestyle risk factors.

Cancer-Therapy-Related Cardiac Dysfunction: Latest Advances in Prevention and Treatment

The increasing efficacy of cancer therapies has significantly improved survival rates, but it has also highlighted the prevalence of cancer-therapy-related cardiac dysfunction (CTRCD). This review provides a comprehensive overview of the identification, monitoring, and management of CTRCD, a condition resulting from several treatments, such as anthracyclines, HER2-targeted therapies, target therapies, and radiotherapy. The paper includes a discussion of the mechanisms of CTRCD associated with various cancer treatments. Early detection through serum biomarkers and advanced imaging techniques is crucial for effective monitoring and risk stratification. Preventive strategies include pharmacological interventions such as ACE inhibitors/angiotensin receptor blockers, beta-blockers, and statins. Additionally, novel agents like sacubitril/valsartan, sodium-glucose co-transporter type 2 inhibitors, and vericiguat show promise in managing left ventricular dysfunction. Lifestyle modifications, including structured exercise programs and optimized nutritional strategies, further contribute to cardioprotection. The latest treatments for both asymptomatic and symptomatic CTRCD across its various stages are also discussed. Emerging technologies, including genomics, artificial intelligence, novel biomarkers, and gene therapy, are paving the way for personalized approaches to CTRCD prevention and treatment. These advancements hold great promise for improving long-term outcomes in cancer patients by minimizing cardiovascular complications.

Hemodynamic Force Based on Cardiac Magnetic Resonance Imaging: State of the Art and Perspective

Intracardiac blood flow has long been proposed to play a significant role in cardiac morphology and function. However, absolute blood pressure within the heart has mainly been measured by invasive catheterization, which limits its application. Hemodynamic force (HDF) is the global force of intracavitary blood flow acquired by integrating the intraventricular pressure gradient over the entire ventricle and thus may be a promising tool for accurately characterizing cardiac function. Recent advances in magnetic resonance imaging technology allow for a noninvasive measurement of HDF through both 4D flow cardiac MRI and cine cardiac MRI. The HDF time curve provides comprehensive data for both qualitative and quantitative analysis. In this review, a series of HDF parameters is introduced and a summary of the current literature regarding HDF in clinical practice is presented. Additionally, the current dilemmas and future prospects are discussed in order to contribute to the future research. LEVEL OF EVIDENCE: 5. TECHNICAL EFFICACY: Stage 2.

Genetics, Fitness, and Left Ventricular Remodelling: The Current State of Play

Cardiorespiratory fitness (CRF) exists on a spectrum and is driven by a constellation of factors, including genetic and environmental differences. This results in wide interindividual variation in baseline CRF and the ability to improve CRF with regular endurance exercise training. As opposed to monogenic conditions, CRF is described as a complex genetic trait as it is believed to be influenced by multiple common genetic variants in addition to exogenous factors. Importantly, CRF is an independent predictor of morbidity and mortality, and so understanding the impact of genetic variation on CRF may provide insights into both human athletic performance and personalized risk assessment and prevention. Despite rapidly advancing technology, progress in this field has been restricted by small sample sizes and the limited number of genetic studies using the "gold standard" objective measure of peak oxygen consumption (VO2peak) for CRF assessment. In recent years, there has been increasing interest in the heritability of numerous parameters of cardiac structure and function and how this may relate to both normal cardiac physiology and disease pathology. Regular endurance training can result in exercise-induced cardiac remodelling, which manifests as balanced dilation of cardiac chambers and is associated with superior CRF. This results in a complex relationship between CRF, cardiac size, and exercise, and whether shared genetic pathways may influence this remains unknown. In this review we highlight recent and relevant studies into the genomic predictors of CRF with a unique emphasis on how this may relate to cardiac remodelling and human adaptation to endurance exercise.

Left ventricular diastolic and systolic functions by cardiac magnetic resonance in beta-thalassemia major: correlation with clinical findings and cardiac complications

This cross-sectional study explored the association of left ventricular (LV) fractional area change (FAC) with demographic characteristics, clinical data, cardiovascular magnetic resonance (CMR) findings, and cardiac complications (heart failure and arrythmias) in patients with beta-thalassemia major (β-TM). We included 292 β-TM patients (151 females, 36.72 ± 11.76 years) consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia project and 20 healthy controls (8 females, 36.97 ± 3.54 years). CMR was used to assess FAC and derive LV systolic and diastolic indexes, to quantify myocardial iron overload (MIO) by the T2* technique and LV volumes and ejection fraction, and to detect late gadolinium enhancement (LGE). Healthy subjects and β-TM patients showed comparable LV systolic and diastolic indexes. In β-TM, the LV systolic index was significantly correlated with global heart T2* values, and patients with significant MIO (T2*<20ms) were more likely to have a reduced LV systolic index compared to those without MIO (odds ratio-OR = 3.13; p = 0.013). In multivariate analysis, global heart T2* values and positive LGE emerged as independent determinants of the LV systolic index. The number of segments with LGE inversely correlated with the LV systolic index (p = 0.003). Patients with a reduced LV systolic index were more likely to have cardiac diseases than those with a normal LV systolic index (OR = 5.34; p < 0.0001). No significant correlates were found for the LV diastolic index. In well-treated β-TM patients, MIO and LGE were the strongest determinants of the LV systolic index, and a reduced LV systolic index was associated with an increased risk of cardiac complications.

Long-term cardiac MRI follow up of MANTICORE (Multidisciplinary Approach to Novel Therapies in Cardio-Oncology REsearch)

BACKGROUND

This study investigates the long-term cardiac effects of trastuzumab-based chemotherapy in early breast cancer (EBC) survivors. We extend the original MANTICORE trial which showed that angiotensin-converting enzyme inhibitors (ACEI) and beta-blockers (BB) could mitigate the decline in left ventricular (LV) ejection fraction (EF) during the first year of trastuzumab treatment.

OBJECTIVES

We hypothesized that, over time, cardiac function would decline further and adverse changes in cardiac geometry would occur due to the aging of the population and prior treatment.

METHODS

The study enrolled 52 participants from the original MANTICORE trial cohort, with cardiac magnetic resonance (CMR) imaging conducted at a median of 6.5 years post randomization to treatment.

RESULTS

We found that, contrary to the hypothesis, participants maintained LV EF over the follow-up period. Specifically, the placebo group exhibited a recovery in LV EF to levels comparable with the treatment groups, suggesting no long-term differential impact on cardiac function. However, a significant reduction in LV mass was observed across all groups, the clinical implications of which remain unclear.

CONCLUSIONS

The findings suggest that in a selected population receiving trastuzumab-based chemotherapy, extended cardiac imaging surveillance beyond one-year post-treatment may be unnecessary. We posit that the presence of HER2 overexpressing breast cancer influenced hypertrophic changes to cardiac geometry observed at baseline and one year, which resolved after completing HER2-blocking treatment. The study also highlights the need for further research to understand the significance of changes in cardiac geometry during and after breast cancer treatment​.

Advancing Cardiovascular Diagnostics: The Expanding Role of CMR in Heart Failure and Cardiomyopathies

Cardiovascular magnetic resonance (CMR) imaging has become a cornerstone in the diagnosis, risk stratification, and management of cardiovascular disease (CVD), particularly heart failure (HF) and cardiomyopathies. Renowned as the gold standard for non-invasive quantification of ventricular volumes and ejection fraction, CMR delivers superior spatial and temporal resolution with excellent tissue-blood contrast. Recent advancements, including T1, T2, and T2* mapping, extracellular volume quantification, and late gadolinium enhancement, enable precise tissue characterization, allowing early detection of myocardial changes such as fibrosis, edema, and infiltration. These features provide critical insights into the pathophysiological mechanisms underlying HF phenotypes and diverse cardiomyopathies, enhancing diagnostic accuracy and guiding therapeutic decisions. This review explores the expanding role of CMR in CV disease, highlighting its diagnostic value in HF and in several cardiomyopathies, as well as its contribution to improving patient outcomes through detailed tissue characterization and prognosis.

Left ventricular size and heart failure: A cardiac MRI assessment of 38,129 individuals from the UK Biobank

BACKGROUND

Previous studies suggest that prevalent heart failure (HF) differs based on left ventricular ejection fraction (LVEF) and left ventricular (LV) chamber size. Furthermore, the prevalence of HF with preserved ejection fraction (HFpEF) is often considered approaching, or exceeding that of HF with reduced ejection fraction in the community.

AIM

The aim of this study was to evaluate prevalent and incident HF based on LVEF and CMR-determined LV size within a large community-dwelling cohort.

METHODS

Individuals from the United Kingdom Biobank (UKB) who underwent CMR and had available health record linkage to allow ascertainment of HF diagnosis were included. The cohort was analysed according to LVEF, LV end-diastolic volume (LVEDV) quartiles and LVEDV indexed to body surface area (LVEDVi).

RESULTS

38,129 individuals were included, comprising those with reduced LVEF (LVEF<50 %, n = 5096) and preserved LVEF (LVEF 50-60 %, n = 22,907, LVEF≥60 %, n = 10,126). Prevalent HF was highest in males with LVEF<50 %, and participants with reduced LVEF had higher rates of incident HF (p < 0.001) during the follow-up period (median = 2.46 years from CMR). Mean LVEDV and LVEDVi were largest in individuals with EF < 50 % (146.9 ± 36.2 ml and 76.8 ± 16.4 ml/m2 respectively). Compared to the smallest quartiles, the largest quartiles for LVEDV were associated with increased odds of HF (odds ratio 2.14 [95 % confidence interval 1.47-3.12], p < 0.001).

CONCLUSIONS

Over 50 % of HF cases occur in individuals with LVEF ≥50 %, however HF prevalence is highest in those with reduced LVEF, particularly in males. Larger LV size is associated with increased HF across the LVEF spectrum.

Standard breath-hold versus free-breathing real-time cine cardiac MRI-a prospective randomized comparison in patients with known or suspected cardiac disease

Aims

Cardiovascular magnetic resonance (CMR) is established as the reference standard for cardiac volumetric assessment. Despite the accuracy and robustness of steady-state free precession (SSFP) cine imaging, its use may prove challenging in patients with arrhythmia and in those who cannot perform repeated breath holds. An alternative solution may be a free-breathing electrocardiogram (ECG)-triggered, retro-gated, real-time cine sequence. This study sought to compare left ventricular volumetric, wall motion, and thickness assessment with both techniques.

Methods and results

Consecutive patients with known or suspected cardiac disease referred for clinical CMR were studied at 3-Tesla. Participants underwent short-axis standard SSFP and real-time cine imaging in a randomized order within the same scan. Between sequence agreement and mean difference were compared for end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume, ejection fraction (EF), left ventricular mass (LVM), maximal wall thickness (MWT), and wall motion score index (WMSi). Two hundred and two patients (mean age 61 ± 14 years, 51% male and 14% irregular rhythm) were studied. All left ventricular indices showed good-excellent agreement between the two methods [intraclass correlation coefficient (95% confidence interval), EDV 0.96 (0.95-0.97), ESV 0.96 (0.94-0.97), EF 0.85 (0.81-0.88), LVM 0.93 (0.91-0.95), MWT 0.80 (0.75-0.85), and WMSi 0.93 (0.91-0.95)].

Conclusion

In patients with known or suspected cardiac disease, real-time cine imaging demonstrates good-excellent reproducibility of LV volumetric, wall thickness and resting wall motion assessment when compared with standard SSFP (Trial registration: NCT05221853).

Long-term follow-up of the TRED-HF trial: Implications for therapy in patients with dilated cardiomyopathy and heart failure remission

AIMS

In TRED-HF, 40% of patients with recovered dilated cardiomyopathy (DCM) relapsed in the short term after therapy withdrawal. This follow-up investigates the longer-term effects of therapy withdrawal.

METHODS AND RESULTS

TRED-HF was a randomized trial investigating heart failure therapy withdrawal in patients with recovered DCM over 6 months. Those randomized to continue therapy subsequently withdrew treatment between 6 and 12 months. Participants were recommended to restart therapy post-trial and were followed until May 2023. Clinical outcomes are reported in a non-randomized fashion from enrolment and from the end of the trial. The primary outcome was relapse defined as ≥10% reduction in left ventricular ejection fraction to <50%, doubling in N-terminal pro-B-type natriuretic peptide to >400 ng/L, or clinical features of heart failure. From enrolment to the last follow-up (median 6 years, interquartile range 6-7), 33 of 51 patients (65%) relapsed. The 5-year relapse rate from enrolment was 61% (95% confidence interval [CI] 45-73) and from the end of the trial was 39% (95% CI 19-54). Of 20 patients who relapsed during the trial, nine had a recurrent relapse during follow-up. Thirteen relapsed for the first time after the trial; seven had restarted low intensity therapy, four had not restarted therapy and two did not have therapy withdrawn. The mean intensity of therapy was lower after the trial compared to enrolment (mean difference -6 [-8 to -4]; p < 0.001). One third of relapses during follow-up had identifiable triggers (arrhythmia [n = 4], pregnancy [n = 1], hypertension [n = 1], infection [n = 1]). Corrected atrial fibrillation was associated with reduced risk of relapse (hazard ratio 0.33, 95% CI 0.12-0.96; p = 0.042).

CONCLUSIONS

The risk of relapse in the 5 years following the TRED-HF trial remained high. Restarting lower doses of heart failure medications at the end of the trial, external triggers and disease progression are likely to have contributed to relapse.

The Role of Advanced Cardiac Imaging in Monitoring Cardiovascular Complications in Patients with Extracardiac Tumors: A Descriptive Review

Cardiac involvement in cancer is increasingly important in the diagnosis and follow-up of patients. A thorough cardiovascular evaluation using multimodal imaging is crucial to assess any direct cardiac involvement from oncological disease progression and to determine the cardiovascular risk of patients undergoing oncological therapies. Early detection of cardiac dysfunction, particularly due to cardiotoxicity from chemotherapy or radiotherapy, is essential to establish the disease's overall prognostic impact. Comprehensive cardiovascular imaging should be integral to the clinical management of cancer patients. Echocardiography remains highly effective for assessing cardiac function, including systolic performance and ventricular filling pressures, with speckle-tracking echocardiography offering early insights into chemotoxicity-related myocardial damage. Cardiac computed tomography (CT) provides precise anatomical detail, especially for cardiac involvement due to metastasis or adjacent mediastinal or lung tumors. Coronary assessment is also important for initial risk stratification and monitoring potential coronary artery disease progression after radiotherapy or chemotherapeutic treatment. Finally, cardiac magnetic resonance (CMR) is the gold standard for myocardial tissue characterization, aiding in the differential diagnosis of cardiac masses. CMR's mapping techniques allow for early detection of myocardial inflammation caused by cardiotoxicity. This review explores the applicability of echocardiography, cardiac CT, and CMR in cancer patients with extracardiac tumors.

Effect of optimisation to contemporary HFrEF medical therapy with sacubitril/valsartan (Entresto) and dapaglifloziN on left Ventricular reverse remodelling as demonstrated by cardiac magnetic resonance (CMR) Imaging: the ENVI study

INTRODUCTION

Heart failure with reduced ejection fraction (HFrEF) guidelines recommend 'four pillars' of medical therapy and device therapy if left ventricular ejection fraction (LVEF) remains ≤35% after 3 months optimum medical therapy.We conducted the first study to examine the effects of optimisation to contemporary medical therapy on cardiac reverse remodelling, as demonstrated by cardiac magnetic resonance imaging (CMR).We hypothesised a proportion of patients would undergo beneficial remodelling and LVEF improvement above the threshold for complex device prescription after 6 months.

METHODS

HFrEF patients with symptomatic LVEF≤35% despite ACE inhibitor/beta blocker/mineralocorticoid receptor antagonist therapy, and qualified for sacubitril/valsartan switchover were recruited to this single centre prospective study.CMR was performed at baseline and at follow-up. Clinical, volumetric and outcome data were collected and compared.

RESULTS

Between June 2021 and August 2022, 49 patients were recruited. The majority (80%) were male, mean age 63±14 years. 35 (71%) had non-ischaemic cardiomyopathy. 2 (4%) patients died and 47 were followed up for a median of 7.4 months. There were no heart failure hospitalisations.Significant reductions were seen in median indexed left atrial volume: 54 mL/m2 (41-72) to 39 mL/m2 (30-60) (p<0.001); indexed left ventricular end-diastolic volume: 109 mL/m2 (74-125) to 76 mL/m2 (58-102) (p<0.001); indexed left ventricular end-systolic volume: 74mL/m2 (50-92) to 43 mL/m2 (27-58) (p<0.001) and mean indexed left ventricular mass: 72±13 g/m2 to 62±13 g/m2 (p<0.001).Median LVEF increased by 12 points from 31% to 43% (p<0.001). 29 (59%) patients improved to LVEF>35%. 13 (27%) patients improved to LVEF≥50%.Median N-terminal pro B type natriuretic peptide (NTproBNP) reduced from 883 ng/L (293-2043) to 429 ng/L (171-1421) (p<0.001).

CONCLUSIONS

Optimisation to contemporary HFrEF medical therapy results in beneficial cardiac reverse remodelling and significant improvements in LVEF and NTproBNP at 6 months as demonstrated by CMR. 59% of our cohort no longer met complex device indications. Guidelines suggest re-assessment of LVEF at 3 months, but our data suggests a longer period is required.

TRIAL REGISTRATION NUMBER

NCT05348226.

Observed and expected reliability of echocardiographic volumetric methods and critical change values for quantification of mitral regurgitant fraction in dogs

BACKGROUND

Reliability of echocardiographic calculations for stroke volume and mitral regurgitant fraction (RFMR) are affected by observer variability and lack of a gold standard. Variability is used to calculate critical change values (CCVs) that are thresholds representing real change in a measure not associated with observer variability.

HYPOTHESIS

Observed intra- and interobserver accuracy and variability in healthy dogs help model CCV for RFMR.

ANIMALS

Reliability cohort of 34 healthy dogs; allometric scaling cohort of 99 dogs with heart disease and 25 healthy dogs.

METHODS

Accuracy, variability, and CCV of 2 observers using geometric and flow-based echocardiography were prospectively compared against a standard of RFMR = 0% and extrapolated across a range of expected RFMR values in the reliability cohort partly derived from cardiac dimensions predicted by the allometric cohort.

RESULTS

Accuracy of methods to determine RFMR in descending order was 4-chamber bullet (Bullet4CH), mitral inflow, cube formula, and Simpson's method of disks. Intraobserver variability was relatively high. The CCV for RFMR ranged from 28% to 88% and was inversely related to RFMR when extrapolated for use in affected dogs. For both observers, the Bullet4CH method had the lowest intraobserver CCV (Operator 1:28%, Operator 2:41%). Interobserver strength of agreement was low with intraclass correlation coefficients ranging from 0.210 to 0.413.

CONCLUSIONS AND CLINICAL IMPORTANCE

Echocardiographic volumetric methods used to calculate stroke volume and RFMR have low accuracy and high variability in healthy dogs. Extrapolation of observed CCV to a range of expected RFMR suggests observers and methods are not interchangeable and variability might hinder routine clinical usage. Individual observers should be aware of their own variability and CCV.

CMR to characterize myocardial structure and function in heart failure with preserved left ventricular ejection fraction

Despite remarkable progress in therapeutic drugs, morbidity, and mortality for heart failure (HF) remains high in developed countries. HF with preserved ejection fraction (HFpEF) now accounts for around half of all HF cases. It is a heterogeneous disease, with multiple aetiologies, and as such poses a significant diagnostic challenge. Cardiac magnetic resonance (CMR) has become a valuable non-invasive modality to assess cardiac morphology and function, but beyond that, the multi-parametric nature of CMR allows novel approaches to characterize haemodynamics and with magnetic resonance spectroscopy (MRS), the study of metabolism. Furthermore, exercise CMR, when combined with lung water imaging provides an in-depth understanding of the underlying pathophysiological and mechanistic processes in HFpEF. Thus, CMR provides a comprehensive phenotyping tool for HFpEF, which points towards a targeted and personalized therapy with improved diagnostics and prevention.

Preventing broken hearts in women with breast cancer: a concise review on chemotherapy-mediated cardiotoxicity

Cancer and cardiovascular disease are the leading causes of death for Canadian women. One in eight Canadian women will receive the life-changing diagnosis of breast cancer (BC) in their lifetime, with 1 in 34 dying from the disease. Although doxorubicin (DOX) and trastuzumab (TRZ) have significantly improved survival in women diagnosed with human epidermal growth factor receptor 2 (HER2)-positive BC, approximately one in four women who receive this treatment are at risk of developing chemotherapy-induced cardiotoxicity. Cardiotoxicity is defined as a decline in left ventricular ejection fraction (LVEF) of >10% to an absolute value of <53%. Current guidelines recommend the serial monitoring of LVEF in this patient population using non-invasive cardiac imaging modalities including transthoracic echocardiography or multi-gated acquisition scan; however, this will only allow for the detection of established cardiotoxicity. Recent studies have demonstrated that a reduction in global longitudinal strain by speckle tracking echocardiography can identify pre-clinical systolic dysfunction prior to a decline in overall LVEF. Implementation of early detection techniques would allow for the prompt initiation of cardioprotective strategies. In addition to the early detection of chemotherapy-mediated cardiotoxicity, the prophylactic use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, statins, exercise, and nutraceutical therapies have been studied in the setting of cardio-oncology.

C-Reactive Protein: An Important Inflammatory Marker of Coronary Atherosclerotic Disease

Cardiovascular disease (CVD) is the most common cause of death worldwide, with coronary atherosclerotic heart disease (CHD) accounting for the majority of events. Evidence demonstrates that inflammation plays a vital role in the development of CHD. The association between C-reactive protein (CRP), a representative inflammatory biomarker, and atherosclerosis (AS), CHD, and inflammation has attracted attention. Therefore, we conducted an extensive search on PubMed using the aforementioned terms as search criteria and identified a total of 1246 articles published from January 2000 to April 2024. Both review and research-based articles consistently indicate CRP as a risk enhancer for CVD, contributing to the refinement of risk stratification and early identification of apparently healthy at-risk populations. Additionally, CRP reflects disease progression and predicts the prognosis of recurrent cardiovascular events. Anti-inflammatory therapeutic strategies targeting CRP also provide new treatment options for patients. This review focuses on the link between CRP and CHD, highlighting how CRP is involved in the pathological progression of AS and its potential value for clinical applications.

Echocardiographic assessment of left ventricular volumes: a comparison of different methods in athletes

BACKGROUND

Cardiac magnetic resonance imaging (cMRI) is considered the gold standard for the assessment of left ventricular (LV) systolic function. However, discrepancies have been reported in the literature between LV volumes assessed by transthoracic echocardiography (TTE) and cMRI. The objective of this study was to analyze the differences in LV volumes between different echocardiographic techniques and cMRI.

METHODS AND RESULTS

In 64 male athletes (21.1 ± 4.9 years), LV volumes were measured by TTE using the following methods: Doppler echocardiography, anatomical M-Mode, biplane/triplane planimetry and 3D volumetry. In addition, LV end-diastolic (LVEDV), end-systolic (LVESV), and stroke volumes (LVSV) were assessed in 11 athletes by both TTE and cMRI. There was no significant difference between LVEDV and LVESV determined by biplane/triplane planimetry and 3D volumetry. LVEDV and LVESV measured by M-Mode were significantly lower compared to 3D volumetry. LVSV determined by Doppler with 3D planimetry of LV outflow tract was significantly higher than 2D planimetry and 3D volumetry, whereas none of the planimetric or volumetric methods for determining LVSV differed significantly. There were no significant differences for LVEDV, LVESV, LVSV and LVEF between cMRI and TTE determined by biplane planimetry in the subgroup of 11 athletes.

CONCLUSION

The choice of echocardiographic method used has an impact on LVSV in athletes, so the LVSV should always be checked for plausibility. The same echocardiographic method should be used to assess LVSV at follow-ups to ensure good comparability. The data suggest that biplane LV planimetry by TTE is not inferior to cMRI.

Stronger positive correlation of the left ventricular mass index and extracellular volume fraction with diastolic function in diabetic patients without myocardial infarction

BACKGROUND

The structural and functional characteristics of the heart in patients with diabetes mellitus (DM) and without myocardial infarction (MI) are not fully understood.

METHODS

We retrospectively analysed the data of patients with left ventricular ejection fraction (LVEF) ≥ 40% who underwent contrast-enhanced cardiac magnetic resonance imaging (CMR), which was also used to exclude MI, at two hospitals. Volumetric data and extracellular volume fraction (ECVf) of the myocardium evaluated using CMR were compared between patients with and without DM, and their association with diastolic function was evaluated.

RESULTS

Among 322 analysed patients, 53 had DM. CMR revealed that the left ventricular mass index (LVMi) and ECVf were increased while LVEF was decreased in patients with DM after adjusting for patient characteristics (all P < 0.05). A stronger positive correlation was observed between LVMi and the early diastolic transmitral flow velocity to early diastolic mitral annular velocity ratio (E/e') in patients with DM than in those without DM (correlation coefficient [R] = 0.46, p = 0.001; R = 0.15, p = 0.021, respectively; p for interaction = 0.011). ECVf correlated with E/e' only in patients with DM (R = 0.61, p = 0.004).

CONCLUSIONS

Patients with DM have increased LVMi and ECVf. Importantly, there was a difference between patients with and without DM in the relationship between these structural changes and E/e', with a stronger relationship in patients with DM. Furthermore, DM is associated with mildly reduced LVEF even in the absence of MI.

Role of Thiamine Supplementation in the Treatment of Chronic Heart Failure: An Updated Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Chronic heart failure (CHF) has always posed a significant threat to human survival and health. The efficacy of thiamine supplementation in CHF patients remains uncertain.

HYPOTHESIS

Receiving supplementary thiamine may not confer benefits to patients with CHF.

METHODS

A comprehensive search was conducted across the Cochrane Library, PubMed, EMBASE, ClinicalTrials.gov, and Web of Science databases up until May 2023 to identify articles investigating the effects of thiamine supplementation in CHF patients. Predefined criteria were utilized for selecting data on study characteristics and results.

RESULTS

Seven randomized, double-blind, controlled trials (five parallel trials and two crossover trials) involving a total of 274 patients were enrolled. The results of the meta-analysis pooling these studies did not reveal any significant effect of thiamine treatment compared with placebo on left ventricular ejection fraction (WMD = 1.653%, 95% CI:  -1.098 to 4.405, p = 0.239, I2 = 61.8%), left ventricular end-diastolic volume (WMD = -6.831 mL, 95% CI:  -26.367 to 12.704, p = 0.493, I2 = 0.0%), 6-min walking test (WMD = 16.526 m, 95% CI:  -36.582 to 69.634, p = 0.542, I2 = 66.3%), N-terminal pro-B type natriuretic peptide (WMD = 258.150 pg/mL, 95% CI:  -236.406 to 752.707, p = 0.306, I2 = 21.6%), or New York Heart Association class (WMD = -0.223, 95% CI:  -0.781 to 0.335, p = 0.434, I2 = 87.1%). However, it effectively improved the status of thiamine deficiency (TD).

CONCLUSIONS

Our meta-analysis indicates that thiamine supplementation does not have a direct therapeutic effect on CHF, except for correcting TD.

Efficacy of mitral annular velocity as an alternative marker of left ventricular global longitudinal strain to detect the risk of cancer therapy-related cardiac disorders

PURPOSE

Left ventricular longitudinal function can be rapidly evaluated by measuring S' and mitral annular plane systolic excursion (MAPSE) using tissue Doppler imaging. Even when the image quality is poor and the left ventricular endocardium is not visible, S' and MAPSE can be measured if the mitral annulus is visible. However, the utility of S' and MAPSE in diagnosing cancer therapy-related cardiac dysfunction (CTRCD) remains unclear. This study aimed to examine the diagnostic performance of S' and MAPSE and determine appropriate cutoff values.

METHODS

We retrospectively enrolled 279 breast cancer patients who underwent pre- or postoperative chemotherapy with anthracyclines and trastuzumab from April 2020 to November 2022. We compared echocardiographic data before chemotherapy, 6 months after chemotherapy initiation, and 1 year later. CTRCD was defined as a decrease in left ventricular ejection fraction below 50%, with a decrease of ≥10% from baseline or a relative decrease in left ventricular global longitudinal strain (LVGLS) of ≥15%.

RESULTS

A total of 256 participants were included in this study, with a mean age of 50.2 ± 11 years. Fifty-six individuals (22%) developed CTRCD within 1 year after starting chemotherapy. The cutoff value for septal S' was 6.85 cm/s (AUC = .81, p < .001; sensitivity 74%; specificity 73%), and for MAPSE was 11.7 mm (AUC = .65, p = .02; sensitivity 79%; specificity 45%). None of the cases with septal S' exceeding 6.85 cm/s had an LVGLS of ≤15%.

CONCLUSIONS

Septal S' is a useful indicator for diagnosing CTRCD.

HIGHLIGHTS

Septal S' decreased at the same time or earlier than the decrease in LVGLS. The septal S' demonstrated higher diagnostic ability for CTRCD compared to LVGLS.

Eicosapentaenoic acid and Arachidonic acid Protection Against Left Ventricle Pathology: the Multi-Ethnic Study of Atherosclerosis

Background

We have shown that ω3 polyunsaturated fatty acids (PUFAs) reduce risk for heart failure, regardless of ejection fraction status. Ventricular remodeling and reduced ventricular performance precede overt hear failure, however there is little insight into how PUFAs contribute to maladaptive signaling over time. PUFAs are agonists for regulatory activity at g-protein coupled receptors such as Ffar4, and downstream as substrates for monooxygenases (e.g lipoxygenase, cytochrome p450, or cyclooxygenase (COX)) which mediate intracellular adaptive signaling.

Methods

Plasma phospholipid PUFA abundance at Exam 1 as mass percent EPA, DHA, and arachidonic acid (AA) from the Multi-Ethnic Study of Atherosclerosis (MESA) were evaluated using pathway modeling to determine the association with time-dependent changes in left ventricular (LV) mass (LVM), end-diastolic LV volume (EDV), and end-systolic volume (ESV) measured by cardiac MRI at Exams 1 and 5. Ejection fraction (EF) and mass:volume (MV) were calculated posteriorly from the first three.

Results

2,877 subjects had available MRI data. Participants with low AA and EPA had accelerated age-dependent declines in LVM. Males with low AA and EPA also had accelerated declines in EDV, but among females there was no PUFA association with EDV declines and exam 5 EDV status was positively associated with AA. Both sexes had nearly the same positive association of AA with changes in ESV.

Conclusion

Plasma phospholipid AA and EPA are prospectively associated with indices of heart remodeling, including ventricular remodeling and performance. Combined AA and EPA scarcity was associated with the most accelerated age-related changes and exam 5 status, while the greatest benefits were found among participants with both PUFAs. This suggests that both PUFAs are required for optimal slowing of age-related declines in ventricular function.

Cardiac magnetic resonance in advanced heart failure

Heart failure (HF) is a chronic and progressive disease that often progresses to an advanced stage where conventional therapy is insufficient to relieve patients' symptoms. Despite the availability of advanced therapies such as mechanical circulatory support or heart transplantation, the complexity of defining advanced HF, which requires multiple parameters and multimodality assessment, often leads to delays in referral to dedicated specialists with the result of a worsening prognosis. In this review, we aim to explore the role of cardiac magnetic resonance (CMR) in advanced HF by showing how CMR is useful at every step in managing these patients: from diagnosis to prognostic stratification, hemodynamic evaluation, follow-up and advanced therapies such as heart transplantation. The technical challenges of scanning advanced HF patients, which often require troubleshooting of intracardiac devices and dedicated scans, will be also discussed.

Aortic Regurgitation: From Valvular to Myocardial Dysfunction

Chronic aortic regurgitation (AR) leads to volume overload in the left ventricle (LV), which is well tolerated for years. In this condition, the LV usually dilates with minimal reduction in the ejection fraction (EF), even in the absence of symptoms. Echocardiography is the primary imaging test used to quantify AR. However, no single assessment of Doppler measures is accurate and precise in individual patients; therefore, the integration of multiple parameters is necessary. Recent guidelines recommend surgical treatment for severe AR in patients who are symptomatic or have an LVEF < 55% and an end-systolic diameter > 50 mm. Nevertheless, advances in imaging technology have improved the quantification of AR and the assessment of LV subclinical dysfunction. It is widely recognized that patients who undergo aortic valve replacement/repair (AVR) due to symptoms or a low LVEF experience worse outcomes than those undergoing AVR for non-Class I indications. In fact, subclinical irreversible myocardial damage may occur in clinically well-compensated and closely monitored patients while awaiting formal surgical indications. This condition could be prevented by the use of multimodal imaging parameters, in particular longitudinal LV strain and magnetic resonance imaging. In addition, better cut-off values for mortality predictors should be established. This review aims to identify simple models that integrate several echocardiographic and cardiac magnetic resonance-derived parameters to predict the optimal timing of surgical treatment in asymptomatic patients with chronic severe AR.

Postmyocardial Infarction Ventricular Aneurysm: JACC Focus Seminar 5/5

Ventricular aneurysm represents a rare complication of transmural acute myocardial infarction, although other cardiac, congenital, or metabolic diseases may also predispose to such condition. Ventricular expansion includes all the cardiac layers, usually with a large segment involved. Adverse events include recurrent angina, reduced ventricular stroke volume with congestive heart failure, mitral regurgitation, thromboembolism, and ventricular arrhythmias. Multimodality imaging is paramount to provide comprehensive assessment, allowing for appropriate therapeutic decision-making. When indicated, surgical intervention remains the gold standard, although additional therapy (heart failure, anticoagulation, and advanced antiarrhythmic treatment) might be required. However, the STICH (Surgical Treatment for Ischemic Heart Failure) trial did not show any advantage from adding surgical ventricular reconstruction to coronary artery bypass surgery in terms of survival, rehospitalization or symptoms, compared with revascularization alone. Finally, implantable cardiac defibrillator may reduce the risk of fatal arrhythmias.

Assessing Regurgitation Severity, Adverse Remodeling, and Fibrosis with CMR in Aortic Regurgitation

PURPOSE OF REVIEW

Cardiac magnetic resonance (CMR) is emerging as a valuable imaging modality for the assessment of aortic regurgitation (AR). In this review, we discuss the assessment of AR severity, left ventricular (LV) remodeling, and tissue characterization by CMR while highlighting the latest studies and addressing future research needs.

RECENT FINDINGS

Recent studies have further established CMR-based thresholds of AR severity and LV remodeling that are associated with adverse clinical outcomes, and lower than current guideline criteria. In addition, tissue profiling with late gadolinium enhancement (LGE) and extracellular volume (ECV) quantification can reliably assess adverse myocardial tissue remodeling which is also associated with adverse outcomes. The strengths and reproducibility of CMR in evaluating ventricular volumes, tissue characteristics, and regurgitation severity position it as an excellent modality in evaluating and following AR patients. Advanced CMR techniques for the detection of tissue remodeling have shown significant potential and merit further investigation.

Diagnostic value of cardiothoracic ratio in patients with non-ischaemic cardiomyopathy: comparison to cardiovascular magnetic resonance imaging

PURPOSE

To determine the reliability of the cardiothoracic ratio (CTR) as a simple method to assess the cardiac size and function in patients with non-ischemic cardiomyopathy (NICM).

METHODS

In a sample of 91 patients (66 patients with diagnosed non-ischemic cardiomyopathy and 25 controls) we calculated the CTR on a posteroanterior chest radiograph and ventricular and atrial size based on accepted cardiovascular magnetic resonance (CMR) imaging values. Left and right ventricular ejection fraction was also calculated. The CTR and cardiac chamber size were compared between patients with NICM and healthy individuals. The distinction between normal and increased cardiac chamber size was made using published normal CMR reference values stratified by age and gender.

RESULTS

CTR values were higher in the NICM group (50.7±5.5 % Vs. 45.3±4.7 %, p<0.001). Likewise, LVEDVi, LV indexed mass, LA indexed volume, LA indexed area, and RA indexed area were higher, and LVEF and RVEF were lower in patients with non-ischemic cardiomyopathy (p < 0.05). In patients with non-ischemic cardiomyopathy, the greatest correlation between CTR and CMR values was with LVEDVi (ρ=0.4, p < 0.001), LA indexed volume (ρ=0.5, p < 0.001), LA indexed area (ρ=0.5, p < 0.001) and RA indexed area (ρ=0.4, p < 0.001). However, the correlation strength was only moderate.

CONCLUSION

Despite patients with NICM had higher CTR values than the control group, a substantial proportion of these patients showed normal CTRs (<50 %). This fact limits the usefulness of CTR to reliably predict NICM. Correlation between CTR and heart chamber dilation on CMR was only weak to moderate.

Cardiac remodelling in non-alcoholic fatty liver disease in the general population

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease (NAFLD) is associated with increased risk for cardiovascular disease. Our study investigates the contribution of NAFLD to changes in cardiac structure and function in a general population.

METHODS

One thousand ninety-six adults (49.3% female) from the Study of Health in Pomerania underwent magnetic resonance imaging including cardiac and liver imaging. The presence of NAFLD by proton density fat fraction was related to left cardiac structure and function. Results were adjusted for clinical confounders using multivariable linear regression model.

RESULTS

The prevalence for NAFLD was 35.9%. In adjusted multivariable linear regression models, NAFLD was positively associated with higher left ventricular mass index (β = 0.95; 95% confidence interval (CI): 0.45; 1.45), left ventricular concentricity (β = 0.043; 95% CI: 0.031; 0.056), left ventricular end-diastolic wall thickness (β = 0.29; 95% CI: 0.20; 0.38), left atrial end-diastolic volume index (β = 0.67; 95% CI: 0.01; 1.32) and inversely associated with left ventricular end-diastolic volume index (β = -0.78; 95% CI: -1.51; -0.05). When stratified by sex, we only found significant positive associations of NAFLD with left ventricular mass index, left atrial end-diastolic volume index, left ventricular cardiac output and an inverse association with global longitudinal strain in women. In contrast, men had an inverse association with left ventricular end-diastolic volume index and left ventricular stroke volume. Higher liver fat content was stronger associated with higher left ventricular mass index, left ventricular concentricity and left ventricular end-diastolic wall thickness.

CONCLUSION

NAFLD is associated with cardiac remodelling in the general population showing sex specific patterns in cardiac structure and function.

Improvement in Cardiac Morphology Demonstrated by Cardiac Magnetic Resonance Imaging and Echocardiography after Haploidentical Hematopoietic Cell Transplantation in Adults with Sickle Cell Disease

Cardiopulmonary complications account for approximately 40% of deaths in patients with sickle cell disease (SCD). Diffuse myocardial fibrosis, elevated tricuspid regurgitant jet velocity (TRV) and iron overload are all associated with early mortality. Although HLA-matched sibling hematopoietic cell transplantation (HCT) offers a potential cure, less than 20% of patients have a suitable donor. Haploidentical HCT allows for an increased donor pool and has recently demonstrated improved safety and efficacy. Our group has reported improved cardiac morphology via echocardiography at 1 year after HCT. Here we describe the first use of cardiac magnetic resonance imaging (CMR), the gold standard for measuring volume, mass, and ventricular function, to evaluate changes in cardiac morphology post-HCT in adults with SCD. We analyzed baseline and 1-year data from 12 adults with SCD who underwent nonmyeloablative haploidentical peripheral blood HCT at the National Institutes of Health. Patients underwent noncontrast CMR at 3 T, echocardiography, and laboratory studies. At 1 year after HCT, patients showed marked improvement in cardiac chamber morphology by CMR, including left ventricular (LV) mass (70.2 to 60.1 g/m2; P = .02) and volume (114.5 to 90.6 mL/m2; P = .001). Furthermore, mean TRV normalized by 1 year, suggesting that HCT may offer a survival benefit. Fewer patients had pathologically prolonged native myocardial T1 times, an indirect marker of myocardial fibrosis at 1 year; these data showed a trend toward significance. In this small sample, CMR was very sensitive in detecting cardiac mass and volume changes after HCT and provided complementary information to echocardiography. Notably, post-HCT improvement in cardiac parameters can be attributed only in part to the resolution of anemia; further studies are needed to determine the roles of myocardial fibrosis reversal, improved blood flow, and survival impact after HCT for SCD.

Echocardiography versus Cardiac MRI for Measurement of Left Ventricular Ejection Fraction in Individuals with Cancer and Suspected Cardiotoxicity

Purpose To compare left ventricular ejection fraction (LVEF) measured with echocardiography and cardiac MRI in individuals with cancer and suspected cardiotoxicity and assess the potential effect on downstream clinical decision-making. Materials and Methods In this prospective, single-center observational cohort study, participants underwent same-day two-dimensional (2D) echocardiography and cardiac MRI between 2011 and 2021. Participants with suboptimal image quality were excluded. A subset of 74 participants also underwent three-dimensional (3D) echocardiography. The agreement of LVEF derived from each modality was assessed using Bland-Altman analysis and at relevant thresholds for cardiotoxicity. Results A total of 745 participants (mean age, 60 years ± 5 [SD]; 460 [61.7%] female participants) underwent same-day echocardiography and cardiac MRI. According to Bland-Altman analysis, the mean bias was -3.7% ± 7.6 (95% limits of agreement [LOA]: -18.5% to 11.1%) for 2D echocardiography versus cardiac MRI. In 74 participants who underwent cardiac MRI, 3D echocardiography, and 2D echocardiography, the mean LVEFs were 60.0% ± 10.4, 58.4% ± 9.4, and 57.2% ± 8.9, respectively (P < .001). At the 50% LVEF threshold for detection of cardiotoxicity, there was disagreement for 9.3% of participants with 2D echocardiography and cardiac MRI. Agreement was better with 3D echocardiography and cardiac MRI (mean bias, -1.6% ± 6.3 [95% LOA: -13.9% to 10.7%]) compared with 2D echocardiography and cardiac MRI (mean bias, -2.8% ± 6.3 [95% LOA: -15.2% to 9.6%]; P = .016). Conclusion Two-dimensional echocardiography had variations of ±15% for LVEF measurement compared with cardiac MRI in participants with cancer and led to misclassification of approximately 10% of participants for cardiotoxicity detection. Three-dimensional echocardiography had better agreement with cardiac MRI and should be used as first-line imaging. Keywords: Echocardiography, MR Functional Imaging, Cardiac Supplemental material is available for this article. © RSNA, 2024.

Assessment of Feasibility and Interscan Variability of Short-time Cardiac MRI for Cardiotoxicity Evaluation in Breast Cancer

Purpose To investigate the feasibility and interscan variability of short-time cardiac MRI protocol after chemotherapy in individuals with breast cancer. Materials and Methods A total of 13 healthy female controls (mean age, 52.4 years ± 13.2 [SD]) and 85 female participants with breast cancer (mean age, 51.8 years ± 9.9) undergoing chemotherapy prospectively underwent routine breast MRI and short-time cardiac MRI using a 3-T scanner with peripheral pulse gating in the prone position. Interscan, intercoil, and interobserver reproducibility and variability of native T1 and extracellular volume (ECV), as well as ventricular functional parameters, were measured using the intraclass correlation coefficient (ICC), standard error of measurement (SEM), or coefficient of variation (CoV). Results Left ventricular functional parameters had excellent interscan reproducibility (ICC ≥ 0.80). Left ventricular ejection fraction showed low interscan variability in control and chemotherapy participants (SEM, 2.0 and 1.2; CoV, 3.1 and 1.9, respectively). Native T1 showed excellent interscan (ICC, 0.75) and intercoil (ICC, 0.81) reproducibility in the control group and good interscan reproducibility (ICC, 0.72 and 0.73, respectively) in the participants undergoing immediate and remote chemotherapy. Interscan reproducibility for ECV was excellent in the control group and in the remote chemotherapy group (ICC, 0.93 and 0.88, respectively) and fair in the immediate chemotherapy group (ICC, 0.52). In the regional analysis, interscan repeatability and variability of native T1 and ECV were superior in the anteroseptum or inferoseptum than in other segments in the immediate chemotherapy group. Native T1 and ECV had good to excellent interobserver agreement across all groups. Conclusion Short-time cardiac MRI showed excellent results for interscan, intercoil, and interobserver reproducibility and variability for ventricular functional or tissue characterization parameters, suggesting that this modality is feasible for routine surveillance of cardiotoxicity evaluation in individuals with breast cancer. Keywords: Cardiac MRI, Heart, Cardiomyopathy ClinicalTrials.gov registration no. NCT03301389 Supplemental material is available for this article. © RSNA, 2024.

Evaluation of left ventricular function and volume by two-dimensional echocardiography in a pediatric population: Correlation with cardiac magnetic resonance imaging

Background

Echocardiographic quantification of left ventricular (LV) volume and ejection fraction (EF) is widely used in the pediatric population. However, there is no consensus on the most accurate method of quantifying ventricular volumes and systolic function.

Purpose

The purpose of this study is to compare two commonly used echocardiographic methods for the evaluation of LV volume and quantification of EF, the five-sixth area-length (5/6 AL) and the modified biplane Simpson (BS), to cardiac magnetic resonance (CMR) imaging in children.

Methods

CMR studies were paired with echocardiograms and retrospectively analyzed in children 18 years of age and younger. Studies performed more than 3 months between modalities, patients with congenital heart disease, and patients who had changes in medication regimen between corresponding CMR and echocardiograms were excluded. LV volumes and EF were calculated using the 5/6 AL and BS methods and compared to volumes and EF measured on corresponding CMR studies. Subgroup analyses were conducted based on LV function, pathology, and weight.

Results

We retrospectively analyzed 53 CMR and corresponding echocardiogram studies (23 studies for myocarditis and 30 studies for cardiomyopathy) in 46 patients. LVEF derived by both echocardiographic methods showed a good correlation to CMR (5/6 AL r = 0.85 and BS r = 0.82). However, both echocardiographic methods overestimated LVEF and underestimated LV volumes when compared to CMR.

Conclusion

Left ventricular volumes and EF, as measured by echocardiography, correlate well with CMR measurements. Echocardiography underestimates LV systolic and diastolic volumes and overestimates LVEF. While echocardiography is a good surrogate for estimating LVEF, CMR should be considered in patients for whom accurate measurements are needed for critical clinical decision-making.

Effect of variable left ventricular ejection fraction assessed by equilibrium radionuclide angiocardiography using different software packages on the diagnosis of cardiotoxicity in patients with cancer

BACKGROUND

The equilibrium radionuclide angiocardiography (ERNA) scan is an established imaging modality for assessing left ventricular ejection fraction (LVEF) in oncology patients. This study aimed to explore the interchangeability of two commercially available software packages (MIM and JS) for LVEF measurement for a cancer-therapy-related cardiac dysfunction (CTRCD) diagnosis.

METHODS

This is a single-center retrospective study among 322 patients who underwent ERNA scans. A total of 582 scans were re-processed using MIM and JS for cross-sectional and longitudinal LVEF measurements.

RESULTS

The median LVEF for MIM and JS were 56% and 66%, respectively (P < 0.001). LVEF processed by JS was 9.91% higher than by MIM. In 87 patients with longitudinal ERNA scans, serial studies processed by MIM were classified as having CTRCD in a higher proportion than serial studies processed by JS (26.4% vs 11.4%, P = 0.020). There were no significant differences in intra- or inter-observer LVEF measurement variability (R = 0.99, P < 0.001).

CONCLUSIONS

Software packages for processing ERNA studies are not interchangeable; thus, reports of ERNA studies should include details on the post-processing software. Serial ERNA studies should be processed on the same software when feasible to avoid discrepancies in the diagnosis and management of CTRCD.

Individually tailored spatial-spectral pulsed CEST MRI for ratiometric mapping of myocardial energetic species at 3T

PURPOSE

CEST MRI has been used to probe changes in cardiac metabolism via assessment of CEST contrast from Cr. However, B1 variation across the myocardium leads to spatially variable Cr CEST contrast in healthy myocardium.

METHODS

We developed a spatial-spectral (SPSP) saturation pulsed CEST protocol to compensate for B1 variation. Flip angle maps were used to individually tailor SPSP pulses comprised of a train of one-dimensional spatially selective subpulses selective along the principal B1 gradient dimension. Complete Z-spectra in the hearts of (n = 10) healthy individuals were acquired using conventional Gaussian saturation and SPSP schemes and supported by phantom studies.

RESULTS

In simulations, the use of SPSP pulses reduced the average SD of the effective saturation B1 values within the myocardium (n = 10) from 0.12 ± 0.02 μT to 0.05 ± 0.01 μT (p < 0.01) and reduced the average SD of Cr CEST contrast in vivo from 10.0 ± 4.3% to 6.1 ± 3.5% (p < 0.05). Results from the hearts of human subjects showed a significant reduction of CEST contrast distribution at 2 ppm, as well as amplitude, when using SPSP saturation. Corresponding phantom experiments revealed PCr-specific contrast generation at body temperature when SPSP saturation was used but combined PCr and Cr contrast generation when Gaussian saturation was used.

CONCLUSION

The use of SPSP saturation pulsed CEST resulted in PCr-specific contrast generation and enabled ratiometric mapping of PCr to total Cr CEST contrast in the human heart at 3T.

The robustness of the flow-gradient classification of severe aortic stenosis

Objectives

A flow-gradient classification is used to determine the indication for intervention for patients with severe aortic stenosis (AS) with discordant echocardiographic parameters. We investigated the agreement in flow-gradient classification by stroke volume (SV) measurement at the left ventricular outflow tract (LVOT) and at the left ventricle.

Methods

Data were used from a prospective cohort study and patients with severe AS (aortic valve area index ≤0.6 cm2/m2) with preserved ejection fraction (>50%) were selected. SV was determined by an echocardiographic core laboratory at the LVOT and by subtracting the 2-dimensional left ventricle end-systolic from the end-diastolic volume (volumetric). Patients were stratified into 4 groups based on SV index (35 mL/m2) and mean gradient (40 mm Hg). The group composition was compared and the agreement between the SV measurements was investigated using regression, correlation, and limits of agreement. In addition, a systematic LVOT diameter overestimation of 1 mm was simulated to study flow-gradient reclassification.

Results

Of 1118 patients, 699 were eligible. The group composition changed considerably as agreement on flow state occurred in only 50% of the measurements. LVOT SV was on average 15.1 mL (95% limits of agreement -24.9:55.1 mL) greater than volumetric SV. When a systematic 1-mm LVOT diameter overestimation was introduced, the low-flow groups halved.

Conclusions

There was poor agreement in the flow-gradient classification of severe AS as a result of large differences between LVOT and volumetric SV. Furthermore, this classification was sensitive to small measurement errors. These results stress that parameters beyond the flow-gradient classification should be considered to ensure accurate recommendations for intervention.

Utilities and Limitations of Cardiac Magnetic Resonance Imaging in Dilated Cardiomyopathy

Dilated cardiomyopathy (DCM) is one of the most common types of non-ischemic cardiomyopathy. DCM is characterized by left ventricle (LV) dilatation and systolic dysfunction without coronary artery disease or abnormal loading conditions. DCM is not a single disease entity and has a complex historical background of revisions and updates to its definition because of its diverse etiology and clinical manifestations. In cases of LV dilatation and dysfunction, conditions with phenotypic overlap should be excluded before establishing a DCM diagnosis. The differential diagnoses of DCM include ischemic cardiomyopathy, valvular heart disease, burned-out hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, and non-compaction. Cardiac magnetic resonance (CMR) imaging is helpful for evaluating DCM because it provides precise measurements of cardiac size, function, mass, and tissue characterization. Comprehensive analyses using various sequences, including cine imaging, late gadolinium enhancement imaging, and T1 and T2 mapping, may help establish differential diagnoses, etiological work-up, disease stratification, prognostic determination, and follow-up procedures in patients with DCM phenotypes. This article aimed to review the utilities and limitations of CMR in the diagnosis and assessment of DCM.

Predictive value for mortality of left ventricular wall thickness in dilated cardiomyopathy

AIMS

The purpose of this study was to explore the predictive value of wall thickness measured by cardiac magnetic resonance (CMR) for all-cause mortality in dilated cardiomyopathy (DCM) patients.

METHODS AND RESULTS

DCM patients who underwent CMR and completed the regular follow-up were included in this study. The left ventricular end-diastolic diameter (LVDd), left ventricular end-diastolic volume (LVEDV), left ventricular posterior wall thickness (PWT), interventricular septum thickness (IVST), left ventricular ejection fraction, and left ventricular mass (LVM) were measured by CMR. The presence and extent of late gadolinium enhancement (LGE) were also assessed. The relative posterior wall thickness (RWTPW ) and relative interventricular septum wall thickness (RWTIVS ) were defined by the following equations: RWTPW  = (2 × PWT)/LVDd, and RWTIVS  = (2 × IVST)/LVDd. All patients received regular telephone and outpatient follow-up. The primary endpoint was all-cause mortality. A total of 161 patients were enrolled in this study, including 126 (78.3%) males. The mean age was 52.3 ± 13.6 years. During the median follow-up of 47 months (interquartile range 32-57 months), 41 (24.8%) patients died. Compared with the non-death group, LVDd (75.2 ± 11.9 vs. 70.5 ± 8.8 mm; P = 0.025) was greater in the death group, while PWT [5.2 mm (3.7-6.8) vs. 6.9 mm (5.3-8.6); P < 0.001], IVST [8.2 mm (6.5-9.5) vs. 9.3 mm (7.4-10.5); P = 0.005], RWTPW [0.15 (0.11-0.19) vs. 0.20 (0.15-0.25); P < 0.001], RWTIVS [0.22 (0.17-0.26) vs. 0.26 (0.22-0.31); P < 0.001], and LVM/LVEDV ratio (0.5 ± 0.2 vs. 0.7 ± 0.2 g/mL; P < 0.001) were lower. The presence of LGE [LGE(+)] was more frequent in the death group (75.6% vs. 58.3%; P = 0.048). However, the LGE extent was not significantly different between the two groups [4 (1-7) vs. 2 (0-6); P = 0.096]. Multivariate Cox regression analysis showed that PWT [hazard ratio (HR) 0.086, 95% confidence interval (CI) 0.665-0.976; P < 0.05] and RWTPW (HR 0.001, 95% CI 0.000-0.502; P < 0.05) were independent predictors of all-cause death. In contrast, IVST, RWTIVS , and the presence of LGE were not clearly associated with death.

CONCLUSIONS

PWT measured by CMR is an independent predictor of all-cause mortality in DCM patients. However, there was no significant correlation between septum wall thickness and mortality.

The estimation of left ventricular function using prospective ECG-triggered coronary CT angiography

BACKGROUND

Coronary computed tomography angiography (CCTA) is vital for diagnosing coronary artery disease; however, prospective ECG-triggered acquisition, minimizing radiation exposure, limits left ventricular (LV) ejection fraction (EF) evaluation. We aimed to assess the feasibility and utility of LVEF100msec, a new index for estimating LV function using volumetric changes during 100 msec within systole.

METHODS

This retrospective study analyzed patients who underwent prospective ECG-triggered CCTA with systolic acquisition between January 2015 and June 2022. The LVEF100msec was calculated using the maximum and minimum LV volumes among the three phases (300, 350, and 400 msec post-QRS) and expressed as a percentage. Patients were classified into normal, mild-moderately reduced, or severely reduced LV function categories based on the reference test. The LVEF100msec was compared among groups, and the optimal cutoff value of LVEF100msec for predicting severe LV dysfunction was investigated.

RESULTS

The study included 271 patients (median age ​= ​58 years, 52% male). LVEF was normal in 188 (69.4%), mild-moderately reduced in 57 (21.0%), and severely reduced in 26 (9.6%) patients. Median LVEF100msec value was 9.0 (6.7-12.6) for normal LV function, 4.7 (3.1-8.8) for mild-moderately reduced, and 2.9 (1.5-3.8) for severely reduced LV function. LVEF100msec values significantly differed among categories (p ​< ​0.001). The optimal LVEF100msec cutoff for severe LV dysfunction was 4.3%, with an AUC of 0.924, sensitivity of 88%, and specificity of 89%.

CONCLUSION

The LVEF100msec may serve as a valuable indicator of severe LV dysfunction.

Sphingosine-1-phosphate levels are inversely associated with left ventricular and atrial chamber volume and cardiac mass in men : The Study of Health in Pomerania (SHIP)

AIMS

Sphingosine-1-phosphate (S1P) is a signaling lipid, which is involved in several cellular processes including cell growth, proliferation, migration and apoptosis. The associations of serum S1P levels with cardiac geometry and function are still not clear. We investigated the associations of S1P with cardiac structure and systolic function in a population-based sample.

METHODS AND RESULTS

We performed cross-sectional analyses of 858 subjects (467 men; 54.4%), aged 22 to 81 years, from a sub-sample of the population-based Study of Health in Pomerania (SHIP-TREND-0). We analyzed the associations of serum S1P with structural and systolic function left ventricular (LV) and left atrial (LA) parameters as determined by magnetic resonance imaging (MRI) using sex-stratified multivariable-adjusted linear regression models. In men, MRI data showed that a 1 µmol/L lower S1P concentration was associated with an 18.1 mL (95% confidence interval [CI] 3.66-32.6; p = 0.014) larger LV end-diastolic volume (LVEDV), a 0.46 mm (95% CI 0.04-0.89; p = 0.034) greater LV wall thickness (LVWT) and a 16.3 g (95% CI 6.55-26.1; p = 0.001) higher LV mass (LVM). S1P was also associated with a 13.3 mL/beat (95% CI 4.49-22.1; p = 0.003) greater LV stroke volume (LVSV), an 18.7 cJ (95% CI 6.43-30.9; p = 0.003) greater LV stroke work (LVSW) and a 12.6 mL (95% CI 1.03-24.3; p = 0.033) larger LA end-diastolic volume (LAEDV). We did not find any significant associations in women.

CONCLUSIONS

In this population-based sample, lower levels of S1P were associated with higher LV wall thickness and mass, larger LV and LA chamber sizes and greater stroke volume and work of the LV in men, but not in women. Our results indicate that lower levels of S1P were associated with parameters related with cardiac geometry and systolic function in men, but not in women.

Cardiac Magnetic Resonance for Prophylactic Implantable-Cardioverter Defibrillator Therapy in Ischemic Cardiomyopathy: The DERIVATE-ICM International Registry

BACKGROUND

Implantable cardioverter-defibrillator (ICD) therapy is the most effective prophylactic strategy against sudden cardiac death (SCD) in patients with ischemic cardiomyopathy (ICM) and left ventricle ejection fraction (LVEF) ≤35% as detected by transthoracic echocardiograpgy (TTE). This approach has been recently questioned because of the low rate of ICD interventions in patients who received implantation and the not-negligible percentage of patients who experienced SCD despite not fulfilling criteria for implantation.

OBJECTIVES

The DERIVATE-ICM registry (CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy; NCT03352648) is an international, multicenter, and multivendor study to assess the net reclassification improvement (NRI) for the indication of ICD implantation by the use of cardiac magnetic resonance (CMR) as compared to TTE in patients with ICM.

METHODS

A total of 861 patients with ICM (mean age 65 ± 11 years, 86% male) with chronic heart failure and TTE-LVEF <50% participated. Major adverse arrhythmic cardiac events (MAACE) were the primary endpoints.

RESULTS

During a median follow-up of 1,054 days, MAACE occurred in 88 (10.2%). Left ventricular end-diastolic volume index (HR: 1.007 [95% CI: 1.000-1.011]; P = 0.05), CMR-LVEF (HR: 0.972 [95% CI: 0.945-0.999]; P = 0.045) and late gadolinium enhancement (LGE) mass (HR: 1.010 [95% CI: 1.002-1.018]; P = 0.015) were independent predictors of MAACE. A multiparametric CMR weighted predictive derived score identifies subjects at high risk for MAACE compared with TTE-LVEF cutoff of 35% with a NRI of 31.7% (P = 0.007).

CONCLUSIONS

The DERIVATE-ICM registry is a large multicenter registry showing the additional value of CMR to stratify the risk for MAACE in a large cohort of patients with ICM compared with standard of care.

Multimodality Cardiovascular Imaging of Cardiotoxicity Due to Cancer Therapy

Cancer therapies have revolutionized patient survival rates, yet they come with the risk of cardiotoxicity, necessitating effective monitoring and management. The existing guidelines offer a limited empirical basis for practical approaches in various clinical scenarios. This article explores the intricate relationship between cancer therapy and the cardiovascular system, highlighting the role of advanced multimodality imaging in monitoring patients before, during, and after cancer treatment. This review outlines the cardiovascular effects of different cancer therapy classes, offering a comprehensive understanding of their dose- and time-dependent impacts. This paper delves into diverse imaging modalities such as echocardiography, cardiac magnetic resonance imaging, cardiac computed tomography, and nuclear imaging, detailing their strengths and limitations in various conditions due to cancer treatment, such as cardiac dysfunction, myocarditis, coronary artery disease, Takotsubo cardiomyopathy, pulmonary hypertension, arterial hypertension, valvular heart diseases, and heart failure with preserved ejection fraction. Moreover, it underscores the significance of long-term follow-up for cancer survivors and discusses future directions.

Emerging Roles for Artificial Intelligence in Heart Failure Imaging

Artificial intelligence (AI) applications are expanding in cardiac imaging. AI research has shown promise in workflow optimization, disease diagnosis, and integration of clinical and imaging data to predict patient outcomes. The diagnostic and prognostic paradigm of heart failure is heavily reliant on cardiac imaging. As AI becomes increasingly validated and integrated into clinical practice, AI influence on heart failure management will grow. This review discusses areas of current research and potential clinical applications in AI as applied to heart failure cardiac imaging.

Phenotyping heart failure by cardiac magnetic resonance imaging of cardiac macro- and microscopic structure: state of the art review

Heart failure demographics have evolved in past decades with the development of improved diagnostics, therapies, and prevention. Cardiac magnetic resonance (CMR) has developed in a similar timeframe to become the gold-standard non-invasive imaging modality for characterizing diseases causing heart failure. CMR techniques to assess cardiac morphology and function have progressed since their first use in the 1980s. Increasingly efficient acquisition protocols generate high spatial and temporal resolution images in less time. This has enabled new methods of characterizing cardiac systolic and diastolic function such as strain analysis, exercise real-time cine imaging and four-dimensional flow. A key strength of CMR is its ability to non-invasively interrogate the myocardial tissue composition. Gadolinium contrast agents revolutionized non-invasive cardiac imaging with the late gadolinium enhancement technique. Further advances enabled quantitative parametric mapping to increase sensitivity at detecting diffuse pathology. Novel methods such as diffusion tensor imaging and artificial intelligence-enhanced image generation are on the horizon. Magnetic resonance spectroscopy (MRS) provides a window into the molecular environment of the myocardium. Phosphorus (31P) spectroscopy can inform the status of cardiac energetics in health and disease. Proton (1H) spectroscopy complements this by measuring creatine and intramyocardial lipids. Hyperpolarized carbon (13C) spectroscopy is a novel method that could further our understanding of dynamic cardiac metabolism. CMR of other organs such as the lungs may add further depth into phenotypes of heart failure. The vast capabilities of CMR should be deployed and interpreted in context of current heart failure challenges.