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Aims: This study aimed to identify the impact of increased epicardial adipose tissue (EAT) and its regional distribution on cardiac function in patients with diastolic dysfunction. Methods and results: Sixty‐eight patients with exertional dyspnoea (New York Heart Association ≥II), preserved ejection fraction (≥50%), and diastolic dysfunction (E/e′ ≥ 8) underwent rest and stress right heart catheterization, transthoracic echocardiography, and cardiovascular magnetic resonance (CMR). EAT volumes were depicted from CMR short‐axis stacks. First, the impact of increased EAT above the median was investigated. Second, the association of ventricular and atrial EAT with myocardial deformation at rest and during exercise stress was analysed in a multivariable regression analysis. Patients with high EAT had higher HFA‐PEFF and H2FPEFF scores as well as N‐terminal prohormone of brain natriuretic peptide levels (all P < 0.048). They were diagnosed with manifest heart failure with preserved ejection fraction (HFpEF) more frequently (low EAT: 37% vs. high EAT: 64%; P = 0.029) and had signs of adverse remodelling indicated by higher T1 times (P < 0.001). No differences in biventricular volumetry and left ventricular mass (all P > 0.074) were observed. Patients with high EAT had impaired atrial strain at rest and during exercise stress, and impaired ventricular strain during exercise stress. Regionally increased EAT was independently associated with functional impairment of the adjacent chambers. Conclusions: Patients with diastolic dysfunction and increased EAT show more pronounced signs of diastolic functional failure and adverse structural remodelling. Despite similar morphological characteristics, patients with high EAT show significant cardiac functional impairment, in particular in the atria. Our results indicate that regionally increased EAT directly induces atrial functional failure, which represents a distinct pathophysiological feature in HFpEF. [ABSTRACT FROM AUTHOR]

BACKGROUND: It remains unknown to what extent intrinsic atrial cardiomyopathy or left ventricular diastolic dysfunction drive atrial remodeling and functional failure in heart failure with preserved ejection fraction (HFpEF). Computational 3-dimensional (3D) models fitted to cardiovascular magnetic resonance allow state-of-the-art anatomic and functional assessment, and we hypothesized to identify a phenotype linked to HFpEF. Patients with exertional dyspnea and diastolic dysfunction on echocardiography (E/e', >8) were prospectively recruited and classified as HFpEF or noncardiac dyspnea based on right heart catheterization. All patients underwent rest and exercise-stress right heart catheterization and cardiovascular magnetic resonance. Computational 3D anatomic left atrial (LA) models were generated based on short-axis cine sequences. A fully automated pipeline was developed to segment cardiovascular magnetic resonance images and build 3D statistical models of LA shape and find the 3D patterns discriminant between HFpEF and noncardiac dyspnea. In addition, atrial morphology and function were quantified by conventional volumetric analyses and deformation imaging. A clinical follow-up was conducted after 24 months for the evaluation of cardiovascular hospitalization. RESULTS: Beyond atrial size, the 3D LA models revealed roof dilation as the main feature found in masked HFpEF (diagnosed during exercise-stress only) preceding a pattern shift to overall atrial size in overt HFpEF (diagnosed at rest). Characteristics of the 3D model were integrated into the LA HFpEF shape score, a biomarker to characterize the gradual remodeling between noncardiac dyspnea and HFpEF. The LA HFpEF shape score was able to discriminate HFpEF (n=34) to noncardiac dyspnea (n=34; area under the curve, 0.81) and was associated with a risk for atrial fibrillation occurrence (hazard ratio, 1.02 [95% CI, 1.01-1.04]; P=0.003), as well as cardiovascular hospitalization (hazard ratio, 1.02 [95% CI, 1.00-1.04]; P=0.043). CONCLUSIONS:' LA roof dilation is an early remodeling pattern in masked HFpEF advancing to overall LA enlargement in overt HFpEF. These distinct features predict the occurrence of atrial fibrillation and cardiovascular hospitalization. [ABSTRACT FROM AUTHOR]

Background: Increased daytime sleepiness is a frequently reported symptom in patients with pronounced dysgnathia. Objectives: This study investigated possible correlations using home peripheral arterial tonometry (PAT) and oropharyngeal airway volume determination in patients with dysgnathia and daytime sleepiness. Methods: Twenty patients (13 male, median age 27.6 ± 6.8 years) with abnormal sleep history and 10 skeletal neutral configured controls (6 male, median age 29.5 ± 4.2 years) with normal sleep history were examined. Patients and controls were evaluated for apnoea–hypopnoea index (AHI), respiratory disturbance index (RDI), oxygen desaturation index (ODI), snoring volume (dB), total sleep time (TST) and REM‐percentage (REM). Airway volumetry was measured via CBCT. Individual user experience for PAT was assessed using the User Experience Questionnaire (UEQ). Results: Patients had significantly higher respiratory scores than controls. AHI increased 4.6‐fold (p =.006), RDI 2.5‐fold (p =.008) and ODI 6.4‐fold (p <.001). Oropharyngeal volumes showed a 30% decrease (p =.003). dB, TST and REM showed no significant differences. AHI (r = −.51; p =.005), ODI (r = −.60; p <.001) and RDI (r = −.45; p =.016) correlated negatively with pharyngeal volume. Wits appraisal correlated negatively with oropharyngeal volume (r = −.47; p =.010) and positively with AHI (r =.41; p =.03) and ODI (r =.49; p =.007). dB and TST (r = −.49; p =.008) and REM and RDI (r = −.43; p =.02) correlated negatively. UEQ‐KPI (2.17 ± 0.24) confirmed excellent usability of PAT. Conclusion: Patients with mandibular retrognathia and abnormal sleep history showed significantly higher respiratory indices and smaller oropharyngeal volumes than neutrally configured controls. The dygnathia severity directly influenced the risk of obstructive sleep apnoea. [ABSTRACT FROM AUTHOR]

Aims: There is evidence to suggest that the subtype of aortic stenosis (AS), the degree of myocardial fibrosis (MF), and level of aortic valve calcification (AVC) are associated with adverse cardiac outcome in AS. Because little is known about their respective contribution, we sought to investigate their relative importance and interplay as well as their association with adverse cardiac events following transcatheter aortic valve replacement (TAVR). Methods and results: One hundred consecutive patients with severe AS and indication for TAVR were prospectively enrolled between January 2017 and October 2018. Patients underwent transthoracic echocardiography, multidetector computed tomography, and left ventricular endomyocardial biopsies at the time of TAVR. The final study cohort consisted of 92 patients with a completed study protocol, 39 (42.4%) of whom showed a normal ejection fraction (EF) high‐gradient (NEFHG) AS, 13 (14.1%) a low EF high‐gradient (LEFHG) AS, 25 (27.2%) a low EF low‐gradient (LEFLG) AS, and 15 (16.3%) a paradoxical low‐flow, low‐gradient (PLFLG) AS. The high‐gradient phenotypes (NEFHG and LEFHG) showed the largest amount of AVC (807 ± 421 and 813 ± 281 mm3, respectively) as compared with the low‐gradient phenotypes (LEFLG and PLFLG; 503 ± 326 and 555 ± 594 mm3, respectively, P < 0.05). Conversely, MF was most prevalent in low‐output phenotypes (LEFLG > LEFHG > PLFLG > NEFHG, P < 0.05). This was paralleled by a greater cardiovascular (CV) mortality within 600 days after TAVR (LEFLG 28% > PLFLG 26.7% > LEFHG 15.4% > NEFHG 2.5%; P = 0.023). In patients with a high MF burden, a higher AVC was associated with a lower mortality following TAVR (P = 0.045, hazard ratio 0.261, 95% confidence interval 0.07–0.97). Conclusions: MF is associated with adverse CV outcome following TAVR, which is most prevalent in low EF situations. In the presence of large MF burden, patients with large AVC have better outcome following TAVR. Conversely, worse outcome in large MF and relatively little AVC may be explained by a relative prominence of an underlying cardiomyopathy. The better survival rates in large AVC patients following TAVR indicate TAVR induced relief of severe AS‐associated pressure overload with subsequently improved outcome. [ABSTRACT FROM AUTHOR]

Left atrial and ventricular (LA/LV) dysfunction are interlinked in heart failure with preserved ejection fraction (HFpEF); however, little is known about their interplay and relation to cardiac decompensation. We hypothesized that cardiovascular magnetic resonance (CMR) left atrioventricular coupling index (LACI) would identify pathophysiological alterations in HFpEF and be amenable to rest and ergometer-stress CMR. Patients with exertional dyspnoea, signs of diastolic dysfunction (E/e' ≥ 8), and preserved ejection fraction (EF; ≥ 50%) on echocardiography were prospectively recruited and classified as HFpEF (n = 34) or noncardiac dyspnoea (NCD, n = 34) according to pulmonary capillary wedge pressure (PCWP) on right-heart catheterization (rest/stress ≥ 15/25 mmHg). LA and LV volumes were assessed on short-axis real-time cine sequences at rest and during exercise stress. LACI was defined as the ratio of the LA-to-LV end-diastolic volume. Cardiovascular hospitalization (CVH) was assessed after 24 mo. Volume-derived LA (P ≥ 0.008) but not LV (P ≥ 0.347) morphology and function at rest and during exercise stress detected significant differences comparing HFpEF and NCD. There was impaired atrioventricular coupling in HFpEF at rest (LACI, 45.7% vs. 31.6%, P < 0.001) and during exercise stress (45.7% vs. 27.9%, P < 0.001). LACI correlated with PCWP at rest (r = 0.48, P < 0.001) and during exercise stress (r = 0.55, P < 0.001). At rest, LACI was the only volumetry-derived parameter to differentiate patients with NCD from patients with HFpEF, which were identified using exercise-stress thresholds (P = 0.001). Resting and exercise-stress LACI dichotomized at their medians were associated with CVH (P ≤ 0.005). Assessment of LACI is a simple approach for LA/LV coupling quantification and allows easy and fast identification of heart failure with preserved ejection fraction (HFpEF). [ABSTRACT FROM AUTHOR]

Aims: The REDUCE‐LAP II trial demonstrated adverse outcomes after interatrial shunt device (IASD) placement in heart failure with preserved ejection fraction (HFpEF) attributed to latent pulmonary vascular disease (PVD). We hypothesized that exercise stress cardiovascular magnetic resonance (CMR) imaging could provide non‐invasive characterization of cardiac and pulmonary physiology for improved patient selection. Methods and results: The HFpEF‐Stress trial prospectively enrolled 75 patients with exertional dyspnoea and diastolic dysfunction. Patients underwent rest and exercise stress right heart catheterization, echocardiography and CMR imaging. Pulmonary artery and capillary wedge pressures, cardiac index (CI) and pulmonary vascular resistance (PVR) were calculated. Latent PVD was defined as increased PVR ≥ 1.74 Wood units during exercise stress. CMR assessed long‐axis strains (LAS) and filling volumes of all cardiac chambers. Right ventricular (RV) function was further quantified by stroke and peak flow volumes. Patients with latent PVD (n = 24) showed lower RV function (rest tricuspid annular plane systolic excursion, p = 0.010; stress RV LAS, p < 0.001) compared to patients without (n = 43). During exercise stress, RV stroke and peak flow volumes (p < 0.001) were reduced and led to impaired left atrial filling (p = 0.040) with a strong statistical trend to impaired ventricular (LV) filling (p = 0.098). This subsequently resulted in reduced LV‐CI (p < 0.001) despite preserved LV systolic function (LV LAS p ≥ 0.255). The degree of RV dysfunction during exercise stress best predicted latent PVD (RV peak flow, area under the curve at rest 0.73 vs. stress 0.89, p = 0.004). Conclusions: Latent PVD is a feature of HFpEF and is associated with impaired RV functional reserve, global diastolic filling and LV‐CI. This can be quantified by CMR and used to identify patients likely to benefit from IASD implantation. [ABSTRACT FROM AUTHOR]

Aims Deformation imaging enables optimized risk prediction following acute myocardial infarction (AMI). However, costly and time-consuming post processing has hindered widespread clinical implementation. Since manual left-ventricular long-axis strain (LV LAS) has been successfully proposed as a simple alternative for LV deformation imaging, we aimed at the validation of left-atrial (LA) LAS. Methods and results The AIDA STEMI and TATORT-NSTEMI trials recruited 795 patients with ST-elevation myocardial infarction and 440 with non-ST-elevation myocardial infarction. LA LAS was assessed as the systolic distance change between the middle of a line connecting the origins of the mitral leaflets and either a perpendicular line towards the posterior atrial wall (LAS90) or a line connecting to the O LA posterior portion of the greatest distance irrespective of a predefined angle (LAS). Primary endpoint was major adverse cardiac event (MACE) occurrence within 12 months. There were no significant differences between LA LAS and LAS90, both with excellent reproducibility. LA LAS correlated significantly with LA reservoir function (Es, r = 0.60, P < 0.001). Impaired LA LAS resulted in higher MACE occurrence [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.82-0.88, P < 0.001]. LA LAS (HR 0.90, 95% CI 0.83-0.97, P = 0.005) and LV global longitudinal strain (GLS, P = 0.025) were the only independent predictors o for MACE in multivariate analyses. C-statistics demonstrated incremental value of LA LAS in addition to GLS (P = 0.016) and non- e inferiority compared with FT Es (area under the receiver operating characteristic curve 0.74 vs. 0.69, P = 0.256). Conclusion Left-atrial LAS provides fast and software-independent approximations of quantitative LA function with similar value for risk prediction compared with dedicated deformation imaging. Clinical trial registration ClinicalTrials.gov: NCT00712101 and NCT01612312 [ABSTRACT FROM AUTHOR]

Background: Cardiovascular magnetic resonance imaging is considered the reference standard for assessing cardiac morphology and function and has demonstrated prognostic utility in patients undergoing transcatheter aortic valve replacement (TAVR). Novel fully automated analyses may facilitate data analyses but have not yet been compared against conventional manual data acquisition in patients with severe aortic stenosis (AS).Methods: Fully automated and manual biventricular assessments were performed in 139 AS patients scheduled for TAVR using commercially available software (suiteHEART®, Neosoft; QMass®, Medis Medical Imaging Systems). Volumetric assessment included left ventricular (LV) mass, LV/right ventricular (RV) end-diastolic/end-systolic volume, LV/RV stroke volume, and LV/RV ejection fraction (EF). Results of fully automated and manual analyses were compared. Regression analyses and receiver operator characteristics including area under the curve (AUC) calculation for prediction of the primary study endpoint cardiovascular (CV) death were performed.Results: Fully automated and manual assessment of LVEF revealed similar prediction of CV mortality in univariable (manual: hazard ratio (HR) 0.970 (95% CI 0.943-0.997) p=0.032; automated: HR 0.967 (95% CI 0.939-0.995) p=0.022) and multivariable analyses (model 1: (including significant univariable parameters) manual: HR 0.968 (95% CI 0.938-0.999) p=0.043; automated: HR 0.963 [95% CI 0.933-0.995] p=0.024; model 2: (including CV risk factors) manual: HR 0.962 (95% CI 0.920-0.996) p=0.027; automated: HR 0.954 (95% CI 0.920-0.989) p=0.011). There were no differences in AUC (LVEF fully automated: 0.686; manual: 0.661; p=0.21). Absolute values of LV volumes differed significantly between automated and manual approaches (p < 0.001 for all). Fully automated quantification resulted in a time saving of 10 minutes per patient.Conclusion: Fully automated biventricular volumetric assessments enable efficient and equal risk prediction compared to conventional manual approaches. In addition to significant time saving, this may provide the tools for optimized clinical management and stratification of patients with severe AS undergoing TAVR. [ABSTRACT FROM AUTHOR]

Background: Right heart catheterization using exercise stress is the reference standard for the diagnosis of heart failure with preserved ejection fraction (HFpEF) but carries the risk of the invasive procedure. We hypothesized that real-time cardiac magnetic resonance (RT-CMR) exercise imaging with pathophysiologic data at excellent temporal and spatial resolution may represent a contemporary noninvasive alternative for diagnosing HFpEF.Methods: The HFpEF-Stress trial (CMR Exercise Stress Testing in HFpEF; URL: https://www.clinicaltrials.gov; Unique identifier: NCT03260621. URL: https://dzhk.de/; Unique identifier: DZHK-17) prospectively recruited 75 patients with echocardiographic signs of diastolic dysfunction and dyspnea on exertion (E/e'>8, New York Heart Association class ≥II) to undergo echocardiography, right heart catheterization, and RT-CMR at rest and during exercise stress. HFpEF was defined according to pulmonary capillary wedge pressure (≥15 mm Hg at rest or ≥25 mm Hg during exercise stress). RT-CMR functional assessments included time-volume curves for total and early (1/3) diastolic left ventricular filling, left atrial (LA) emptying, and left ventricular/LA long axis strain.Results: Patients with HFpEF (n=34; median pulmonary capillary wedge pressure at rest, 13 mm Hg; at stress, 27 mm Hg) had higher E/e' (12.5 versus 9.15), NT-proBNP (N-terminal pro-B-type natriuretic peptide; 255 versus 75 ng/L), and LA volume index (43.8 versus 36.2 mL/m2) compared with patients with noncardiac dyspnea (n=34; rest, 8 mm Hg; stress, 18 mm Hg; P≤0.001 for all). Seven patients were excluded because of the presence of non-HFpEF cardiac disease causing dyspnea on imaging. There were no differences in RT-CMR left ventricular total and early diastolic filling at rest and during exercise stress (P≥0.164) between patients with HFpEF and noncardiac dyspnea. RT-CMR revealed significantly impaired LA total and early (P<0.001) diastolic emptying in patients with HFpEF during exercise stress. RT-CMR exercise stress LA long axis strain was independently associated with HFpEF (adjusted odds ratio, 0.657 [95% CI, 0.516-0.838]; P=0.001) after adjustment for clinical and imaging measures and emerged as the best predictor for HFpEF (area under the curve at rest 0.82 versus exercise stress 0.93; P=0.029).Conclusions: RT-CMR allows highly accurate identification of HFpEF during physiologic exercise and qualifies as a suitable noninvasive diagnostic alternative. These results will need to be confirmed in multicenter prospective research studies to establish widespread routine clinical use. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03260621. URL: https://dzhk.de/; Unique identifier: DZHK-17. [ABSTRACT FROM AUTHOR]

Purpose: Myocardial feature‐tracking (FT) deformation imaging is superior for risk stratification compared with volumetric approaches. Because there is no clear recommendation regarding FT postprocessing, we compared different FT‐strain analyses with reference standard techniques, including tagging and strain‐encoded (SENC) MRI. Methods: Feature‐tracking software from four different vendors (TomTec, Medis, Circle [CVI], and Neosoft), tagging (Segment), and fastSENC (MyoStrain) were used to determine left ventricular global circumferential strains (GCS) and longitudinal strains (GLS) in 12 healthy volunteers and 12 patients with heart failure. Variability and agreements were assessed using intraclass correlation coefficients for absolute agreement (ICCa) and consistency (ICCc) as well as Pearson correlation coefficients. Results: For FT‐GCS, consistency was excellent comparing different FT vendors (ICCc = 0.84‐0.97, r = 0.86‐0.95) and in comparison to fast SENC (ICCc = 0.78‐0.89, r = 0.73‐0.81). FT‐GCS consistency was excellent compared with tagging (ICCc = 0.79‐0.85, r = 0.74‐0.77) except for TomTec (ICCc = 0.68, r = 0.72). Absolute FT‐GCS agreements among FT vendors were highest for CVI and Medis (ICCa = 0.96) and lowest for TomTec and Neosoft (ICCa = 0.32). Similarly, absolute FT‐GCS agreements were excellent for CVI and Medis compared with both tagging and fast SENC (ICCa = 0.84‐0.88), good to excellent for Neosoft (ICCa = 0.77 and 0.64), and lowest for TomTec (ICCa = 0.41 and 0.47). For FT‐GLS, consistency was excellent (ICCc ≥ 0.86, r ≥ 0.76). Absolute agreements among FT vendors were excellent (ICCa = 0.91‐0.93) or good to excellent for TomTec (ICCa = 0.69‐0.85). Absolute agreements (ICCa) were good (CVI 0.70, Medis 0.60) and fair (TomTec 0.41, Neosoft 0.59) compared with tagging, but excellent compared with fast SENC (ICCa = 0.77‐0.90). Conclusion: Although absolute agreements differ depending on deformation assessment approaches, consistency and correlation are consistently high regardless of the method chosen, thus indicating reliable strain assessment. Further standardisation and introduction of uniform references is warranted for routine clinical implementation. [ABSTRACT FROM AUTHOR]

Type 2 diabetes predicts outcome following acute myocardial infarction (AMI). Since underlying mechanics are incompletely understood, we investigated left ventricular (LV) and left atrial (LA) pathophysiological changes and their prognostic implications using cardiovascular magnetic resonance (CMR). Consecutive patients (N = 1,147; n = 265 with diabetes, n = 882 without diabetes) underwent CMR 3 days after AMI. Analyses included LV ejection fraction (LVEF); global longitudinal strain (GLS) and circumferential and radial strains; LA reservoir, conduit, and booster pump strains; and infarct size, edema, and microvascular obstruction. Predefined end points were major adverse cardiovascular events (MACE) within 12 months. Patients with diabetes had impaired LA reservoir (19.8% vs. 21.2%, P < 0.01) and conduit (7.6% vs. 9.0%, P < 0.01) strains but not ventricular function or myocardial damage. They were at higher risk of MACE than patients without diabetes (10.2% vs. 5.8%, P < 0.01), with most MACE occurring in patients with LVEF ≥35%. While LVEF (P = 0.045) and atrial reservoir strain (P = 0.024) were independent predictors of MACE in patients without diabetes, GLS was in patients with diabetes (P = 0.010). Considering patients with diabetes and LVEF ≥35% (n = 237), GLS and LA reservoir strain below median were significantly associated with MACE. In conclusion, in patients with diabetes, LA and LV longitudinal strain permit optimized risk assessment early after reperfused AMI with incremental prognostic value over and above that of LVEF. [ABSTRACT FROM AUTHOR]

Aims Cardiovascular magnetic resonance feature tracking (CMR-FT) global longitudinal strain (GLS) provides incremental prognostic value following acute myocardial infarction (AMI) but requires substantial post-processing. Alternatively, manual global long-axis strain (LAS) can be easily assessed from standard steady state free precession images. We aimed to define the prognostic value of LAS in a large multicentre study in patients following AMI. Methods and results A total of 1235 patients with myocardial infarction [ n  = 795 with ST-elevation myocardial infarction (STEMI) and 440 with non-ST-elevation myocardial infarction (NSTEMI)] underwent cardiovascular magnetic resonance imaging after primary percutaneous coronary intervention in eight centres across Germany. Assessment of LAS was performed in a blinded core-laboratory measuring the systolic shortening between the epicardial apical border and the middle of a line connecting the origins of the mitral leaflets. Primary clinical endpoint was the occurrence of major adverse clinical events (MACE) including death, reinfarction, and congestive heart failure within 1 year after AMI. During 1-year follow-up, 76 patients suffered from MACE. Impaired LAS was associated with higher MACE occurrence both in STEMI (P  < 0.001) and NSTEMI (P  = 0.001) patients. Association of LAS remained significant (P  = 0.017) after correction for univariate significant parameters for MACE prediction. C-statistics revealed incremental value of additional LAS assessment for optimized event prediction compared with left ventricular ejection fraction (MACE P  = 0.044; mortality P  = 0.013) and a combination of established clinical and imaging parameters (MACE P  = 0.084; mortality P  = 0.027), but not CMR-FT GLS (MACE P  = 0.075; mortality P  = 0.380). Conclusion LAS provides software independent, widely available, easy and fast approximation of longitudinal left ventricular shortening early after reperfused AMI with incremental prognostic value beyond established risk stratification parameters. Clinical Trials.gov NCT00712101 and NCT01612312. [ABSTRACT FROM AUTHOR]

Aims The exact pathophysiology of Takotsubo syndrome (TTS) remains not fully understood with most studies focussing on ventricular pathology. Since atrial involvement may have a significant role, we assessed the diagnostic and prognostic potential of atrial cardiovascular magnetic resonance feature tracking (CMR-FT) in TTS. Methods and results This multicentre study recruited 152 TTS patients who underwent CMR on average within 3 days after hospitalization. Reservoir [total strain ε s and peak positive strain rate (SR) SRs], conduit (passive strain ε e and peak early negative SRe), and booster pump function (active strain ε a and peak late negative SRa) were assessed in a core laboratory. Results were compared with 21 control patients with normal biventricular function. A total of 20 patients underwent follow-up CMR (median 3.5 months, interquartile range 3–5). All patients were approached for general follow-up. Left atrial (LA) but not right atrial (RA) reservoir and conduit function were impaired during the acute phase (ε s: P  = 0.043, ε e: P  < 0.001, SRe: P  = 0.047 vs. controls) and recovered until follow-up (ε s: P  < 0.001, SRs: P  = 0.04, ε e: P  = 0.001, SRe: P  = 0.04). LA and RA booster pump function were increased in the acute setting (LA- ε a: P  = 0.045, SRa: P  = 0.002 and RA- ε a: P  = 0.004, SRa: P  = 0.002 vs. controls). LA- ε s predicted mortality [hazard ratio 1.10, 95% confidence interval (CI) 1.01–1.20; P  = 0.037] irrespectively of established cardiovascular risk factors (P  = 0.019, multivariate analysis) including left ventricular ejection fraction (LVEF) (area under the curve 0.71, 95% CI 0.55–0.86, P  = 0.048). Conclusion TTS pathophysiology comprises transient impairments in LA reservoir and conduit functions and enhanced bi-atrial active booster pump functions. Atrial CMR-FT may evolve as a superior marker of adverse events over and above established parameters such as LVEF and atrial volume. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular magnetic resonance feature tracking (CMR-FT) is increasingly used for myocardial deformation assessment including ventricular strain, showing prognostic value beyond established risk markers if used in experienced centres. Little is known about the impact of appropriate training on CMR-FT performance. Consequently, this study aimed to evaluate the impact of training on observer variance using different commercially available CMR-FT software. Methods: Intra- and inter-observer reproducibility was assessed prior to and after dedicated one-hour observer training. Employed FT software included 3 different commercially available platforms (TomTec, Medis, Circle). Left (LV) and right (RV) ventricular global longitudinal as well as LV circumferential and radial strains (GLS, GCS and GRS) were studied in 12 heart failure patients and 12 healthy volunteers. Results: Training improved intra- and inter-observer reproducibility. GCS and LV GLS showed the highest reproducibility before (ICC >0.86 and >0.81) and after training (ICC >0.91 and >0.92). RV GLS and GRS were more susceptible to tracking inaccuracies and reproducibility was lower. Inter-observer reproducibility was lower than intra-observer reproducibility prior to training with more pronounced improvements after training. Before training, LV strain reproducibility was lower in healthy volunteers as compared to patients with no differences after training. Whilst LV strain reproducibility was sufficient within individual software solutions inter-software comparisons revealed considerable software related variance. Conclusion: Observer experience is an important source of variance in CMR-FT derived strain assessment. Dedicated observer training significantly improves reproducibility with most profound benefits in states of high myocardial contractility and potential to facilitate widespread clinical implementation due to optimized robustness and diagnostic performance. [ABSTRACT FROM AUTHOR]

Aortic valve calcification (AVC) in aortic stenosis patients has diagnostic and prognostic implications. Little is known about the interchangeability of AVC obtained from different multidetector computed tomography (MDCT) software solutions. Contrast-enhanced MDCT data sets of 50 randomly selected aortic stenosis patients were analysed using three different software vendors (3Mensio, CVI42, Syngo.Via). A subset of 10 patients were analysed twice for the estimation of intra-observer variability. Intra- and inter-observer variability were determined using the ICC reliability method, Bland-Altman analysis and coefficients of variation. No differences were revealed between the software solutions in the AVC calculations (3Mensio 941 ± 623, Syngo.Via 948 mm3 ± 655, CVI42 941 ± 637; p = 0.455). The best inter-vendor agreement was found between the CVI42 and the Syngo.Via (ICC 0.997 (CI 0.995–0.998)), followed by the 3Mensio and the CVI42 (ICC 0.996 (CI 0.922–0.998)), and the 3Mensio and the Syngo.Via (ICC 0.992 (CI 0.986–0.995)). There was excellent intra- (3Mensio: ICC 0.999 (0.995–1.000); CVI42: ICC 1.000 (0.999–1.000); Syngo.Via: ICC 0.998 (0.993–1.000)) and inter-observer variability (3Mensio: ICC 1.000 (0.999–1.000); CVI42: ICC 1.000 (1.000–1.000); Syngo.Via: ICC 0.996 (0.985–0.999)) for all software types. Contrast-enhanced MDCT-derived AVC scores are interchangeable between and reproducible within different commercially available software solutions. This is important since sufficient reproducibility, interchangeability and valid results represent prerequisites for accurate TAVR planning and its widespread clinical use. [ABSTRACT FROM AUTHOR]

Cardiac magnetic resonance (CMR)-derived left ventricular (LV) global longitudinal strain (GLS) provides incremental prognostic information on various cardiovascular diseases but has not yet been investigated comprehensively in patients with Takotsubo syndrome (TS). This study evaluated the prognostic value of feature tracking (FT) GLS, tissue tracking (TT) GLS, and fast manual long axis strain (LAS) in 147 patients with TS, who underwent CMR at a median of 2 days after admission. Long-term mortality was assessed 3 years after the acute event. In contrast to LV ejection fraction and tissue characteristics, impaired FT-GLS, TT-GLS and fast manual LAS were associated with adverse outcome. The best cutoff points for the prediction of long-term mortality were similar with all three approaches: FT-GLS −11.28%, TT-GLS −11.45%, and fast manual LAS −10.86%. Long-term mortality rates were significantly higher in patients with FT-GLS > −11.28% (25.0% versus 9.8%; p = 0.029), TT-GLS > −11.45% (20.0% versus 5.4%; p = 0.016), and LAS > −10.86% (23.3% versus 6.6%; p = 0.014). However, in multivariable analysis, diabetes mellitus (p = 0.001), atrial fibrillation (p = 0.001), malignancy (p = 0.006), and physical triggers (p = 0.006) outperformed measures of myocardial strain and emerged as the strongest, independent predictors of long-term mortality in TS. In conclusion, CMR-based longitudinal strain provides valuable prognostic information in patients with TS, regardless of the utilized technique of assessment. Long-term mortality, however, is mainly determined by comorbidities. [ABSTRACT FROM AUTHOR]

Background: Right ventricular (RV) function is a known predictor of adverse events in heart failure and following acute myocardial infarction (AMI). While right atrial (RA) involvement is well characterized in pulmonary arterial hypertension, its relative contributions to adverse events following AMI especially in patients with heart failure and congestion need further evaluation. Methods: In this cardiovascular magnetic resonance (CMR)-substudy of AIDA STEMI and TATORT NSTEMI, 1235 AMI patients underwent CMR after primary percutaneous coronary intervention (PCI) in 15 centers across Germany (n = 795 with ST-elevation myocardial infarction and 440 with non-ST-elevation MI). Right atrial (RA) performance was evaluated using CMR myocardial feature tracking (CMR-FT) for the assessment of RA reservoir (total strain εs), conduit (passive strain εe), booster pump function (active strain εa), and associated strain rates (SR) in a blinded core-laboratory. The primary endpoint was the occurrence of major adverse cardiac events (MACE) 12 months post AMI. Results: RA reservoir (εsp = 0.061, SRs p = 0.049) and conduit functions (εep = 0.006, SRe p = 0.030) were impaired in patients with MACE as opposed to RA booster pump (εap = 0.579, SRa p = 0.118) and RA volume index (p = 0.866). RA conduit function was associated with the clinical onset of heart failure and MACE independently of RV systolic function and atrial fibrillation (AF) (multivariable analysis hazard ratio 0.95, 95% confidence interval 0.92 to 0.99, p = 0.009), while RV systolic function and AF were not independent prognosticators. Furthermore, RA conduit strain identified low- and high-risk groups within patients with reduced RV systolic function (p = 0.019 on log rank testing). Conclusions: RA impairment is a distinct feature and independent risk factor in patients following AMI and can be easily assessed using CMR-FT-derived quantification of RA strain. [ABSTRACT FROM AUTHOR]