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Background Cardiovascular magnetic resonance (CMR) is increasingly used for risk stratification in aortic stenosis (AS). However, the relative prognostic power of CMR markers and their respective thresholds remains undefined. Objectives Using machine learning, the study aimed to identify prognostically important CMR markers in AS and their thresholds of mortality. Methods Patients with severe AS undergoing AVR (n = 440, derivation; n = 359, validation cohort) were prospectively enrolled across 13 international sites (median 3.8 years’ follow-up). CMR was performed shortly before surgical or transcatheter AVR. A random survival forest model was built using 29 variables (13 CMR) with post-AVR death as the outcome. Results There were 52 deaths in the derivation cohort and 51 deaths in the validation cohort. The 4 most predictive CMR markers were extracellular volume fraction, late gadolinium enhancement, indexed left ventricular end-diastolic volume (LVEDVi), and right ventricular ejection fraction. Across the whole cohort and in asymptomatic patients, risk-adjusted predicted mortality increased strongly once extracellular volume fraction exceeded 27%, while late gadolinium enhancement >2% showed persistent high risk. Increased mortality was also observed with both large (LVEDVi >80 mL/m2) and small (LVEDVi ≤55 mL/m2) ventricles, and with high (>80%) and low (≤50%) right ventricular ejection fraction. The predictability was improved when these 4 markers were added to clinical factors (3-year C-index: 0.778 vs 0.739). The prognostic thresholds and risk stratification by CMR variables were reproduced in the validation cohort. Conclusions Machine learning identified myocardial fibrosis and biventricular remodeling markers as the top predictors of survival in AS and highlighted their nonlinear association with mortality. These markers may have potential in optimizing the decision of AVR.

Funding Acknowledgements Type of funding sources: None. onbehalf The BSCMR Valve Consortium Background Patients with low-flow aortic stenosis (LF-AS) have higher mortality than those with high-flow severe AS. The conventional echocardiographic definition of LF-AS is an indexed stroke volume (SVi) Purpose To determine the association between CMR SVi, myocardial remodelling and survival in severe symptomatic AS. Methods In a multi-centre longitudinal outcome study of patients with severe AS listed for either surgical (SAVR) or transcatheter aortic valve intervention (TAVI) at six cardiothoracic centres, survival was assessed and stratified by SVi. Patients underwent preprocedural echocardiography and CMR between January 2003 and May 2015. Standardised core-lab analyses on pre-procedural CMR for biventricular volumes, function and scar quantification were performed. All-cause and cardiovascular mortality were tracked for a minimum of two years after AVR. Results A total of 674 patients with severe AS (age 75 ± 14years; 63% male, aortic valve area 0.4 ± 0.1 cm2/m2) were included. Patients with low SVi by CMR Conclusion SVi by CMR is an independent predictor of cardiovascular mortality. Mortality hazard increases progressively below a SVi of 50mL/m2. Abstract Figure 1

Background:Myocardial fibrosis is a key mechanism of left ventricular decompensation in aortic stenosis and can be quantified using cardiovascular magnetic resonance (CMR) measures such as extracellular volume fraction (ECV%). Outcomes following aortic valve intervention may be linked to the presence and extent of myocardial fibrosis. Objectives:This study sought to determine associations between ECV% and markers of left ventricular decompensation and post-intervention clinical outcomes. Methods:Patients with severe aortic stenosis underwent CMR, including ECV% quantification using modified Look-Locker inversion recovery–based T1 mapping and late gadolinium enhancement before aortic valve intervention. A central core laboratory quantified CMR parameters. Results:Four-hundred forty patients (age 70 ± 10 years, 59% male) from 10 international centers underwent CMR a median of 15 days (IQR: 4to58 days) before aortic valve intervention. ECV% did not vary by scanner manufacturer, magnetic field strength, or T1 mapping sequence (all p > 0.20). ECV% correlated with markers of left ventricular decompensation including left ventricular mass, left atrial volume, New York Heart Association functional class III/IV, late gadolinium enhancement, and lower left ventricular ejection fraction (p Conclusions:In patients with severe aortic stenosis scheduled for aortic valve intervention, an increased ECV% isameasure of left ventricular decompensation and a powerful independent predictor of mortality.

Background Spironolactone may have prognostic benefit in selected patients with heart failure with preserved ejection fraction. This study assessed the myocardial tissue effects of spironolactone in heart failure with preserved ejection fraction. Methods and Results A 1:1 randomized controlled study of 6 months of spironolactone versus control in heart failure with preserved ejection fraction. The primary outcome was change in myocardial extracellular volume fraction by cardiovascular magnetic resonance as a surrogate of diffuse fibrosis. Of 55 randomized patients, 40 (20 women; age, 75.2±5.9 years) completed follow‐up (19 treatment, 21 control). A significant change in extracellular volume over the study period was not seen (treatment, 28.7±3.7% versus 27.7±3.4% [ P =0.14]; controls, 27.6±3.4% versus 28.3±4.4% [ P =0.14]); however, the rate of extracellular volume expansion was decreased by spironolactone (−1.0±2.4% versus 0.8±2.2%). Indexed left ventricular mass decreased with treatment (104.4±26.6 versus 94.0±20.6 g/m 2 ; P =0.001) but not in controls (101.4±29.4 versus 104.0±32.8 g/m 2 ; P =0.111). Extracellular mass decreased by 13.8% (15.1±4.8 versus 13.0±3.4 g/m 2 ; P =0.003), and cellular mass decreased by 8.3% (37.6±10.0 versus 34.3±7.9 g/m 2 ; P =0.001) with spironolactone, but was static in controls. Conclusions Spironolactone did not lead to significant change in extracellular volume. However, spironolactone did decrease rate of extracellular expansion, with a decrease in the mass of both cellular and extracellular myocardial compartments. These data point to the mechanism of action of spironolactone in heart failure with preserved ejection fraction, including a direct tissue effect with a reduction in rate of myocardial fibrosis.

Current echocardiographic data reporting the impact of concomitant mitral regurgitation (MR) on outcome in patients who undergo transcatheter aortic valve replacement (TAVR) are conflicting. Using cardiovascular magnetic resonance (CMR) imaging, this study aimed to assess the impact of MR severity on cardiac reverse remodeling and patient outcome. 85 patients undergoing TAVR with CMR pre- and 6 m post-TAVR were evaluated. The CMR protocol included cines for left (LV) and right ventricular (RV) volumes, flow assessment, and myocardial scar assessment by late gadolinium enhancement (LGE). Patients were dichotomised according to CMR severity of MR fraction at baseline (‘non-significant’ vs ‘significant’) and followed up for a median duration of 3 years. Forty-two (49%) patients had ‘significant MR’ at baseline; they had similar LV and RV size and function compared to the ‘non-significant MR’ group but had greater LV mass at baseline. In those with significant MR at baseline, 77% (n = 32) had a reduction in MR post-TAVR, moving them into the ‘non-significant’ category at 6-months, with an overall reduction in MR fraction from 34 to 17% (p

Myocardial perfusion imaging during hyperaemic stress is commonly used to detect coronary artery disease. The aim of this study was to investigate the relationship between left ventricular global longitudinal strain (GLS), strain rate (GLSR), myocardial early (E’) and late diastolic velocities (A’) with adenosine stress first-pass perfusion cardiovascular magnetic resonance (CMR) imaging. 44 patients met the inclusion criteria and underwent CMR imaging. The CMR imaging protocol included: rest/stress horizontal long-axis (HLA) cine, rest/stress first-pass adenosine perfusion and late gadolinium enhancement imaging. Rest and stress HLA cine CMR images were analysed using feature-tracking software for the assessment of myocardial deformation. The presence of perfusion defects was scored on a binomial scale. In patients with hyperaemia-induced perfusion defects, rest global longitudinal strain GLS (−16.9 ± 3.7 vs. −19.6 ± 3.4; p-value = 0.02), E’ (−86 ± 22 vs. −109 ± 38; p-value = 0.02), GLSR (69 ± 31 vs. 93 ± 38; p-value = 0.01) and stress GLS (−16.5 ± 4 vs. −21 ± 3.1; p < 0.001) were significantly reduced when compared with patients with no perfusion defects. Stress GLS was the strongest independent predictor of perfusion defects (odds ratio 1.43 95% confidence interval 1.14–1.78, p-value

Aims To test the hypothesis that patients with ischaemic cardiomyopathy (ICM) and non-ischaemic cardiomyopathy (NICM) have different torsion and strain parameters, and compare to healthy, age-matched controls. VINDICATE investigated efficacy of high-dose vitamin D on patients with heart failure (HF) secondary to left ventricular (LV) systolic dysfunction of any aetiology. It is important to differentiate ICM and NICM as treatment and prognosis varies significantly. Cardiovascular magnetic resonance (CMR) reliably determines aetiology of HF and tissue tagging techniques are recognized as the reference standard measures of strain and torsion. Methods and results Fifty three patients (31 ICM, 22 NICM) from VINDICATE and 25 controls underwent CMR at 3.0T, including cine imaging in multiple planes and tissue tagging by spatial modulation of magnetization. CMR data were analysed blinded, by quantitatively reporting circumferential strain and torsion from tagged images and global longitudinal strain from feature tracking. HF patients had larger ventricles indexed to body surface area, lower left ventricular ejection fraction (LVEF), LV torsion, twist, and strain parameters compared to controls. There were no significant differences between ICM and NICM in age, blood pressure, heart rhythm, or NYHA status. There was no significant difference in LV dimensions, EF, and strain parameters between ICM and NICM. NICM patients had significantly lower LV twist (6.0 ± 3.7° vs. 8.8 ± 4.3°, P = 0.023) and torsion (5.9 ± 3.5° vs. 8.8 ± 4.7°, P = 0.017) compared to ICM. Conclusion Twist, torsion, and strain are reduced in HF patients compared to controls. Torsion and twist are significantly lower in patients with NICM compared to ICM, despite similar volumetric dimensions, circumferential and longitudinal strain parameters, and LVEF.

AIMS Myocardial injury assessed using cardiac biomarker release is ubiquitous following surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI), preventing accurate discrimination between focal myocardial infarction (MI) and global injury. Cardiovascular magnetic resonance (CMR) late gadolinium enhancement (LGE) imaging was used to compare rates of new MI following SAVR and TAVI. METHODS AND RESULTS Identical CMR scans were obtained at baseline and six months post procedure in ninety-six patients undergoing SAVR (n=39) and TAVI (n=57). The rate of new MI was greater following SAVR than TAVI (SAVR, n=10 [26%] vs. TAVI, n=3 [5%], p=0.004). Infarct mass was similar between groups (SAVR 1.1±0.6 vs. TAVI 2.0±1.4 g, p=0.395). New MI did not impact on change in LV ejection fraction (SAVR:LGE[+]2.2±4.7 vs. LGE[-]0.9±8.0%, p=0.437, TAVI:LGE[+]-0.9±6.0 vs. LGE[-]2.0±7.8%, p=0.420). Thirty-four patients (60%) in the TAVI group had non-revascularised coronary artery disease (CAD) at the time of TAVI, of whom three (9%) had new MI. CONCLUSIONS MI is an infrequent complication of TAVI but is more common following SAVR. Infarct size is small following both procedures. The low new infarct rate in TAVI, especially in the context of high rates of non-revascularised CAD, strengthens data from previous studies suggesting that coronary revascularisation pre-TAVI may be unnecessary.

Background: Symptomatic severe aortic stenosis (AS) is a class I indication for replacement in patients when left ventricular ejection fraction (LVEF) is preserved. However, symptom reporting is often equivocal and decision making can be challenging. We aimed to quantify myocardial deformation using cardiovascular magnetic resonance (CMR) in patients classified by symptom severity. Methods: Forty-two patients with severe AS referred to heart valve clinic were studied using tagged CMR imaging. All had preserved LVEF. Patients were grouped by symptoms as either “none/mild” (n=21, NYHA class I, II) or “significant” (n=21, NYHA class III, IV, angina, syncope) but were comparable for age (72.8±5.4 vs . 71.0±6.8 years old, P=0.345), surgical risk (EuroSCORE II: 1.90±1.7 vs . 1.31±0.4, P=0.302) and haemodynamics (peak aortic gradient: 55.1±20.8 vs . 50.4±15.6, P=0.450). Thirteen controls matched in age and LVEF were also studied. LV circumferential strain was calculated using inTag © software and longitudinal strain using feature tracking analysis. Results: Compared to healthy controls, patients with severe AS had significantly worse longitudinal and circumferential strain, regardless of symptom status. Patients with “significant” symptoms had significantly worse peak longitudinal systolic strain rates (−83.352±24.802%/s vs . −106.301±43.276%/s, P=0.048) than those with “no/mild” symptoms, with comparable peak longitudinal strain (PLS), peak circumferential strain and systolic and diastolic strain rates. Conclusions: Patients with severe AS who have no or only mild symptoms exhibit comparable reduction in circumferential and longitudinal fibre function to those with significant symptoms, in whom AVR is clearly indicated. Given these findings of equivalent subclinical dysfunction, reportedly borderline symptoms should be handled cautiously to avoid potentially adverse delays in intervention.

Background The right ventricle (RV) is relatively understudied and often not routinely assessed in aortic stenosis (AS). However, there are several potential reasons for its importance. RV function is sensitive to left-sided afterload changes which can result in pulmonary hypertension (PH) in severe AS. PH is also a recognised predictor of poor prognosis in AS, but RV afterload and function can be difficult to assess. Cardiovascular magnetic resonance (CMR) may reveal unrecognised RV dysfunction and simultaneously evaluate other prognostic markers in AS. Purpose To investigate preoperative RV function assessed by CMR in severe AS and its association with mortality after aortic valve replacement (AVR). Methods 674 severe AS patients listed for either surgical or percutaneous AVR at six cardiothoracic centres underwent preoperative CMR (for ventricular function, mass and scar) along with echocardiography for valve severity. Scans were core-lab analysed for LV and RV volumes, function and scar quantification. Eight patients were excluded due to inadequate RV image quality for a total of 666 patients finally included. All-cause mortality was tracked for a minimum of 2 years after AVR. Results 107 (16%) of severe AS undergoing invasive AVR had a RV ejection fraction (RVEF) Cox and Kaplan-Meier for all-cause death Conclusion One out of 6 patients with severe AS undergoing valve replacement manifests a reduction in RV function detectable by CMR. Those with RV dysfunction (RVEF Acknowledgement/Funding British Heart Foundation and National Institute of Health Research

Background Mitral valve (MV) repair is currently recommended over replacement (1). The guidelines suggesting this are however based on historic evidence which compared outdated techniques of MV replacement. Recent data cast doubts on its validity in the current era of chordal-preservation techniques in MV replacement. Purpose Using cardiovascular magnetic resonance (CMR) imaging, this study aimed to assess the impact of MV repair and MV replacement on cardiac left ventricular (LV) reverse remodelling. Methods 65 patients with moderate-severe and severe mitral regurgitation (MR) were prospectively recruited. Of these, 37 patients (59% men, 65±15 years) to date with paired CMR scans at baseline and at 6 months were evaluated. Patients either underwent MV repair (n=9), MV replacement (n=10) or watchful waiting (n=18). The CMR protocol included cines for left ventricle (LV), left atria (LA), and aortic flow assessment. The LA and LV parameters, and MR fraction were analysed. Results At 6 months, both the MV repair and replacement groups exhibited a reduction in LV end-diastolic volume (LVEDV) and LA volumes when compared to the control group. The indexed LVEDV decreased significantly from 129±33ml/m2 to 99±37ml/m2, p Conclusion MV surgery leads to atrial and left ventricular reverse remodelling, and a decline in global LV ejection fraction. In this small series, MV replacement with chordal preservation showed similar cardiac reverse remodelling benefits to MV repair. Although residual MR is often seen following repair, this did not lead to less favourable cardiac reverse remodelling. Acknowledgement/Funding Leeds NIHR infrastructure

Background Diffuse myocardial fibrosis is a key decompensation mechanism in advanced aortic stenosis (AS) and can be quantified using CMR T1 mapping techniques. Purpose To assess T1 mapping measures of fibrosis in patients with severe AS referred for aortic valve replacement, and determine their associations with clinical characteristics, disease severity and clinical outcome. Methods In this international prospective cohort study, patients with severe AS underwent CMR at 1.5T and 3T (Siemens/Philips) with T1 mapping prior to AVR. Image analysis was performed (CVI42, Circle) by a single core laboratory for three T1 mapping measures (native T1, extracellular volume fraction [ECV%] and indexed extracellular volume [iECV=LVMi*ECV%]). Results Four-hundred patients (70±10 years, 60% male) from nine international centres (Canada/Germany/Korea/USA/UK) were enrolled (including 144 patients from BSCMR AS700 study). AVR was performed (SAVR: n=342, TAVI: n=58) 19 [4-61] days following CMR, with median of 3.8 [1.7–4.5] years follow-up and 40 deaths recorded. As expected, native T1 was higher at 3T than 1.5T (1213±57 versus 1050±48 ms, p 0.30); therefore, only ECV-based measures were analysed. ECV% correlated with increasing age, Society of Thoracic Surgeons Predicted Risk of Mortality score, known coronary artery disease, lower aortic valve peak velocity, increased LV mass, presence of late gadolinium enhancement (LGE) and reduced LVEF (p A progressive increase in all-cause mortality was seen across tertiles of ECV% (14.0, 28.5 and 53.7 deaths per 1000 patient-years; log-rank test, p=0.003). ECV% was independently associated with all-cause mortality following adjustment for age, sex, peak velocity, impaired LVEF and presence of LGE (HR per% increase in ECV%: 1.13, 95%, 1.04–1.24, p=0.006). iECV was associated with all-cause mortality following adjustment for age and sex (HR 1.03 95% 1.00–1.06, p=0.04) but not after adjustment for the above clinical variables. Conclusion In patients with severe AS scheduled for AVR, extracellular volume-based T1 mapping measures are robust, track with LV decompensation, and independently predict late all-cause mortality.

ObjectiveTo compare the incidence of silent cerebral infarction and impact on cognitive function following transcatheter aortic valve implantation (TAVI) with the first-generation CoreValve (Medtronic, Minneapolis, Minnesota, USA) and second-generation Lotus valve (Boston Scientific, Natick Massachusetts, USA).DesignA prospective observational study comprising a 1.5 T cerebral MRI scan, performed preoperatively and immediately following TAVI, and neurocognitive assessments performed at baseline, 30 days and 1 year follow-up.SettingUniversity hospitals of Leeds and Leicester, UK.Patients66 (80.6±8.0 years, 47% male) patients with high-risk severe symptomatic aortic stenosis recruited between April 2012 and May 2015.Main outcome measuresIncidence of new cerebral microinfarction and objective decline in neurocognitive performance.ResultsAll underwent cerebral MRI at baseline and immediately following TAVI, and 49 (25 Lotus, 24 CoreValve) completed neurocognitive assessments at baseline, 30 days and 1 year. There was a significantly greater incidence of new cerebral microinfarction observed following the Lotus TAVI (23 (79%) vs 22 (59%), p=0.025) with a greater number of new infarcts per patient (median 3.5 (IQR 7.0) vs 2.0 (IQR 3.0), p=0.002). The mean volume of infarcted cerebral tissue per patient was equivalent following the two prostheses (p=0.166). More patients suffered new anterior (14 (48%) vs 2 (5%), p=0.001) and vertebrobasilar (15 (52%) vs 7 (19%), p=0.005) lesions following Lotus. Lotus was associated with a decline in verbal memory and psychomotor speed at 30 days. However, performance longitudinally at 1 year was preserved in all neurocognitive domains.ConclusionsThere was a higher incidence of silent cerebral microinfarction and a greater number of lesions per patient following Lotus compared with CoreValve. However, there was no objective decline in neurocognitive function discernible at 1 year following TAVI with either prosthesis.

Objective: The response of the RV following treatment of aortic stenosis is poorly defined, reflecting the challenge of accurate RV assessment. Cardiovascular magnetic resonance (CMR) is the established reference for imaging of RV volumes, mass and function. We sought to define the impact of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) upon RV function in patients treated for severe aortic stenosis using CMR. Methods: A 1.5T CMR scan was performed preoperatively and 6 months postoperatively in 112 (56 TAVI, 56 SAVR; 76 ± 8 years) high-risk severe symptomatic aortic stenosis patients across two UK cardiothoracic centres. Results: TAVI patients were older (80.4 ± 6.7 vs. 72.8 ± 7.2 years, p < 0.05) with a higher STS score (2.13 ± 0.73 vs. 5.54 ± 3.41%, p < 0.001). At 6 months, SAVR was associated with a significant increase in RV end systolic volume (33 ± 10 vs. 37 ± 10 ml/m2, p = 0.008), and decrease in RV ejection fraction (58 ± 8 vs. 53 ± 8%, p = 0.005) and tricuspid annular plane systolic excursion (22 ± 5 vs. 14 ± 3 mm, p < 0.001). Only 4 (7%) SAVR patients had new RV late gadolinium hyper-enhancement with no new cases seen in the TAVI patients at 6 months. Longer surgical cross-clamp time was the only predictor of increased RV end systolic volume at 6 months. Post-TAVI, there was no observed change in RV volumes or function. Over a maximum 6.3 year follow-up, 18(32%) of TAVI patients and 1(1.7%) of SAVR patients had died (p = 0.001). On multivariable Cox analysis, the RV mass at 6 m post-TAVI was independently associated with all-cause mortality (HR 1.359, 95% CI 1.108–1.666, p = 0.003). Conclusions: SAVR results in a deterioration in RV systolic volumes and function associated with longer cross-clamp times and is not fully explained by suboptimal RV protection during cardiopulmonary bypass. TAVI had no adverse impact upon RV volumes or function.

Learning objectives Recent technical developments in cardiovascular imaging have led to a number of options for the non-invasive investigation of cardiovascular disease. Often, the choice of imaging modality comes down to local availability and expertise, as in many clinical scenarios there is not one clearly superior test. This is reflected in current international guidelines and recommendations. The relative advantages and disadvantages of each modality are already well published,1 but for many indications, echocardiography, due to its widespread availability and relative low cost, will remain the initial investigation of choice. Single-photon emission computed tomography (SPECT) is the most widely used perfusion test (for known/suspected coronary artery disease (CAD)) the world over, although increasingly CT coronary angiography (CTCA) is used in low-risk cases as an excellent rule-out test. Cardiovascular magnetic resonance (CMR) is an established advanced cross-sectional imaging modality for the functional and anatomical assessment of a wide range of cardiovascular diseases. CMR is safe, does not use ionising radiation, provides diagnostic and prognostic information, and guides patient management.2 ,3 The relative duration of the scan time, expense and lack of portability, however, puts the onus on CMR to demonstrate superiority over other imaging modalities. The extensive and growing evidence base for CMR has established it as the reference standard imaging test for many cardiovascular conditions. As such, CMR is firmly established in both national and international clinical guidelines4–7 with recognised international training syllabi and accreditation/certification processes.8–10 CMR demand continues to expand, particularly in the UK, where there was …

Background— Surgery for severe mitral regurgitation is indicated if symptoms or left ventricular dilation or dysfunction occur. However, prognosis is already reduced by this stage, and earlier surgery on asymptomatic patients has been advocated if valve repair is likely, but identifying suitable patients for early surgery is difficult. Quantifying the regurgitation may help, but evidence for its link with outcome is limited. Cardiovascular magnetic resonance (CMR) can accurately quantify mitral regurgitation, and we examined whether this was associated with the future need for surgery. Methods and Results— One hundred nine asymptomatic patients with echocardiographic moderate or severe mitral regurgitation had baseline CMR scans and were followed up for up to 8 years (mean, 2.5±1.9 years). CMR quantification accurately identified patients who progressed to symptoms or other indications for surgery: 91% of subjects with regurgitant volume ≤55 mL survived to 5 years without surgery compared with only 21% with regurgitant volume >55 mL ( P 40%. CMR-derived end-diastolic volume index showed a weaker association with outcome (proportions surviving without surgery at 5 years, 90% for left ventricular end-diastolic volume index 2 versus 48% for ≥100 mL/m 2 ) and added little to the discriminatory power of regurgitant fraction/volume alone. Conclusions— CMR quantification of mitral regurgitation was associated with the development of symptoms or other indications for surgery and showed better discriminatory ability than the reference-standard CMR-derived ventricular volumes. CMR may be able to identify appropriate patients for early surgery, with the potential to change clinical practice, although the clinical benefits of early surgery require confirmation in a clinical trial.

Objectives: We sought to compare using serial CMR, the quantity of AR and associated valve hemodynamics, following the first‐generation CoreValve (Medtronic, Minneapolis, MN) and the second‐generation Lotus valve (Boston Scientific, Natick, MA).\ud \ud \ud \ud Background: Aortic regurgitation (AR) following Transcatheter Aortic Valve Replacement (TAVR) confers a worse prognosis and can be accurately quantified using cardiovascular magnetic resonance (CMR). Second generation valves have been specifically designed to reduce paravalvular AR and improve clinical outcomes.\ud \ud \ud \ud Methods: Fifty‐one patients (79.0 ± 7.7 years, 57% male) were recruited and imaged at three time points: immediately pre‐ and post‐TAVR, and at 6 months.\ud \ud \ud \ud Results: CMR‐derived AR fraction immediately post‐TAVR was greater in the CoreValve compared to Lotus group (11.7 ± 8.4 vs. 4.3 ± 3.4%, P = 0.001), as was the frequency of ≥moderate AR (9/24 (37.5%) versus 0/27, P

Introduction Myocardial infraction (MI) leads to complex changes in left ventricular (LV) haemodynamics. It remains unknown how four-dimensional (4D) acute changes in LV-cavity blood flow kinetic energy (KE) affect LV remodelling. We hypothesised that LV blood flow energetics is independently associated with adverse LV-remodelling. Methods We recruited 69 revascularised ST-elevation MI patients. All patients underwent cardiovascular magnetic resonance (CMR) at 1.5 T within 48 hours and at 3 months. CMR included cines, early/late gadolinium enhancement and whole-heart 4D flow. CMR analysis included: LV volumes, infarct size (IS,%), microvascular obstruction (MVO,%), two-dimensional, retrospective valve tracking derived mitral inflow metrics and 4D KE components. KE was derived using novel, semi-automated method by using endocardial contours on short-axis cines to extract intra-cavity velocity profile. Adverse LV-remodelling was defined as increase in LV end-diastolic volume by 15%. Results Thirteen (19%) patients developed adverse LV-remodelling. Demographics were comparable between patients with/without remodelling. Baseline CMR in adverse LV-remodelling-group showed significantly lower EF, LV KE, Systolic, A-wave, in-plane KEs and increased MVO (p Conclusion LV haemodynamic assessment by novel, semi-automated, 4D KE mapping adds incremental value to predict adverse LV-remodelling. A-wave KE and MVO size early after acute MI are independently associated with adverse LV-remodelling.

Prior myocardial infarction (MI) is associated with increased mortality and is prevalent in certain high risk patient groups. Electrocardiogram may be used in diagnosis, however, sensitivity is limited, thus non-invasive imaging techniques may improve diagnosis. We investigated whether global longitudinal strain (GLS) and longitudinal strain parameters are reduced in patients with prior MI but preserved left ventricular ejection fraction (LVEF). The study included 40 clinical patients with prior MI occurring >3 months previously (defined as subendocardial hyperenhancement on late Gadolinium enhancement imaging) with LVEF ≥ 55% and 40 controls matched for age and LVEF. GLS, global longitudinal strain rate (GLSR) and early diastolic longitudinal strain rate (GLSRe) were measured from cine imaging feature tracking analysis. Presence of wall motion abnormality (WMA) and minimum systolic wall thickening (SWT) were calculated from cine imaging. GLS was −17.3 ± 3.7% in prior MI versus −19.3 ± 1.9% in controls (p = 0.012). GLSR was −88.0 ± 33.7%/s in prior MI versus −103.3 ± 26.5%/s in controls (p = 0.005). GLSRe was 76.4 ± 28.4%/s in prior MI versus 95.5 ± 26.0%/s in controls (p = 0.001). GLS accurately identified prior MI [AUC 0.662 (95% CI 0.54–0.785) p = 0.012] whereas WMA [AUC 0.500 (95% CI 0.386–0.614) p = 1.0] and minimum SWT [AUC 0.609 (95% CI 0.483–0.735) p = 0.093] did not. GLS, GLSR and GLSRe are reduced in prior MI with preserved LVEF. Normal LVEF and lack of WMA cannot exclude prior MI. Prior MI should be considered when reduced GLS, GLSR or GLSRe are detected by non-invasive imaging.

Background— Late gadolinium enhancement (LGE) imaging overestimates acute infarct size. The main aim of this study was to investigate whether acute extracellular volume (ECV) maps can reliably quantify myocardial area at risk (AAR) and final infarct size (IS). Methods and Results— Fifty patients underwent cardiovascular magnetic resonance imaging acutely (24–72 hours) and at convalescence (3 months). The cardiovascular magnetic resonance protocol included cines, T2-weighted imaging, native T1 maps, 15-minute post-contrast T1 maps, and LGE. Optimal AAR and IS ECV thresholds were derived in a validation group of 10 cases (160 segments). Eight hundred segments (16 per patient) were analyzed to quantify AAR/IS by ECV maps (ECV thresholds for AAR is 33% and IS is 46%), T2-weighted imaging, T1 maps, and acute LGE. Follow-up LGE imaging was used as the reference standard for final IS and viability assessment. The AAR derived from ECV maps (threshold of >33) demonstrated good agreement with T2-weighted imaging–derived AAR (bias, 0.18; 95% confidence interval [CI], −1.6 to 1.3) and AAR derived from native T1 maps (bias=1; 95% CI, −0.37 to 2.4). ECV demonstrated the best linear correlation to final IS at a threshold of >46% ( R =0.96; 95% CI, 0.92–0.98; P P Conclusions— ECV maps can reliably quantify AAR and final IS in reperfused acute myocardial infarction. Acute ECV maps were superior to acute LGE in terms of agreement with final IS. IS quantified by ECV maps are independently associated with viability at follow-up.

Background Expansion of the myocardial extracellular volume (ECV) is a surrogate measure of focal/diffuse fibrosis and is an independent marker of prognosis in chronic heart disease. Changes in ECV may also occur after myocardial infarction, acutely because of oedema and in convalescence as part of ventricular remodelling. The objective of this study was to investigate changes in the pattern of distribution of regional (normal, infarcted and oedematous segments) and global left ventricular (LV) ECV using semi-automated methods early and late after reperfused ST-elevation myocardial infarction (STEMI). Methods Fifty patients underwent cardiovascular magnetic resonance (CMR) imaging acutely (24 h–72 h) and at convalescence (3 months). The CMR protocol included: cines, T2-weighted (T2 W) imaging, pre−/post-contrast T1-maps and LGE-imaging. Using T2 W and LGE imaging on acute scans, 16-segments of the LV were categorised as normal, oedema and infarct. 800 segments (16 per-patient) were analysed for changes in ECV and wall thickening (WT). Results From the acute studies, 325 (40.6%) segments were classified as normal, 246 (30.8%) segments as oedema and 229 (28.6%) segments as infarct. Segmental change in ECV between acute and follow-up studies (Δ ECV) was significantly different for normal, oedema and infarct segments (0.8 ± 6.5%, −1.78 ± 9%, −2.9 ± 10.9%, respectively; P

In the setting of acute ST-elevation myocardial infarction (STEMI), it remains unclear which strain parameter most strongly correlates with microvascular obstruction (MVO) or intramyocardial haemorrhage (IMH). We aimed to investigate the association of MVO, IMH and convalescent left ventricular (LV) remodelling with strain parameters measured with cardiovascular magnetic resonance (CMR). Forty-three patients with reperfused STEMI and 10 age and gender matched healthy controls underwent CMR within 3-days and at 3-months following reperfused STEMI. Cine, T2-weighted, T2*-imaging and late gadolinium enhancement (LGE) imaging were performed. Infarct size, MVO and IMH were quantified. Peak global longitudinal strain (GLS), global radial strain (GRS), global circumferential strain (GCS) and their strain rates were derived by feature tracking analysis of LV short-axis, 4-chamber and 2-chamber cines. All 43 patients and ten controls completed the baseline scan and 34 patients completed 3-month scans. In multivariate regression, GLS demonstrated the strongest association with MVO or IMH (beta = 0.53, p 20%). Baseline GLS also demonstrated the strongest diagnostic performance in predicting adverse LV remodelling (AUC = 0.79; 95% CI 0.60–0.98; p = 0.03). Post-reperfused STEMI, baseline GLS was most closely associated with the presence of MVO or IMH. Baseline GLS was more strongly associated with adverse LV remodelling than other CMR parameters.

Background: Left bundle branch block (LBBB) is common following trans-catheter aortic valve replacement (TAVR) and has been linked to increased mortality, although whether this is related to less favourable cardiac reverse remodeling is unclear. The aim of the study was to investigate the impact of TAVR induced LBBB on cardiac reverse remodeling. Methods: 48 patients undergoing TAVR for severe aortic stenosis were evaluated. 24 patients with new LBBB (LBBB-T) following TAVR were matched with 24 patients with a narrow post-procedure QRS (nQRS). Patients underwent cardiovascular magnetic resonance (CMR) prior to and 6 m post-TAVR. Measured cardiac reverse remodeling parameters included left ventricular (LV) size, ejection fraction (LVEF) and global longitudinal strain (GLS). Inter- and intra-ventricular dyssynchrony were determined using time to peak radial strain derived from CMR Feature Tracking. Results: In the LBBB-T group there was an increase in QRS duration from 96 ± 14 to 151 ± 12 ms (P

Background: Despite the wealth of data showing the positive effects on cardiac reverse remodelling in the long-term, the immediate effects of transcatheter aortic valve implantation (TAVI) on the left ventricle are yet to be comprehensively described using cardiovascular magnetic resonance imaging. Also, the link between myocardial fibrosis and acute left ventricular (LV) mass regression is unknown. Methods: Fifty-seven patients with severe aortic stenosis awaiting TAVI underwent paired cardiovascular magnetic resonance scans before and early after the procedure (4 [interquartile range, 3-5] days). LV mass, volume, and function were measured. Late gadolinium enhancement (LGE) imaging was performed to assess for the presence of and pattern of myocardial fibrosis. Results: After the procedure, 53 (95%) patients experienced an immediate (10.1 ± 7.1%) reduction in indexed LV mass (LVMi) from 76 ± 15.5 to 68.4 ± 14.7 g/m2 (P < 0.001). Those with no LGE experienced the greatest LVMi regression (13.9 ± 7.1%) compared with those with a midwall/focal fibrosis pattern LGE (7.4 ± 5.8%) and infarct pattern LGE (7.2 ± 7.0%; P = 0.005). There was no overall change in LV ejection fraction (LVEF; 55.1 ± 12.1% to 55.5 ± 10.9%; P = 0.867), however a significant improvement in LVEF was seen in those with abnormal (< 55%; n = 24; 42%) baseline LVEF (43.2 ± 8.9 to 46.7 ± 10.5%; P = 0.027). Baseline LVMi (P = 0.005) and myocardial fibrosis (P < 0.001) were strong independent predictors of early LVMi regression. Conclusions: LV reverse remodelling occurs immediately after TAVI, with significant LV mass regression in the total population and an improvement in LVEF in those with preexisting LV impairment. Those without myocardial fibrosis at baseline experience greater LV mass regression than those with fibrosis.

Background It is unknown whether circumferential strain is associated with prognosis after treatment of aortic stenosis (AS). We aimed to characterise strain in severe AS, using myocardial tagging cardiovascular magnetic resonance (CMR), prior to and following Transcatheter Aortic Valve Implantation (TAVI) and Surgical Aortic Valve Replacement (SAVR), and determine whether abnormalities in strain were associated with outcome. Methods CMR was performed pre- and 6 m post-intervention in 98 patients (52 TAVI, 46 SAVR; 77 ± 8 years) with severe AS. TAVI patients were older (80.9 ± 6.4 vs. 73.0 ± 7.0 years, p −18.7% was associated with significantly reduced survival. Conclusion TAVI and SAVR procedures are associated with comparable declines in rotational LV mechanics at 6 m, with largely unchanged strain and strain rates. Pre-operative peak mid LV circumferential strain is associated with post-operative mortality. Electronic supplementary material The online version of this article (doi:10.1186/s12968-017-0329-7) contains supplementary material, which is available to authorized users.

Athletes who train regularly can develop left ventricular (LV) hypertrophy, which can be difficult to differentiate from hypertrophic cardiomyopathy (HCM), the leading cause of sudden cardiac death in young athletes. Current guidelines advise that patients with HCM should avoid competitive sport

Background Athletic training leads to remodelling of both left and right ventricles with increased myocardial mass and cavity dilatation. Whether changes in cardiac strain parameters occur in response to training is less well established. In this study we investigated the relationship in trained athletes between cardiovascular magnetic resonance (CMR) derived strain parameters of cardiac function and fitness. Methods: Thirty five endurance athletes and 35 age and sex matched controls underwent CMR at 3.0 T including cine imaging in multiple planes and tissue tagging by spatial modulation of magnetization (SPAMM). CMR data were analysed quantitatively reporting circumferential strain and torsion from tagged images and left and right ventricular longitudinal strain from feature tracking of cine images. Athletes performed a maximal ramp-incremental exercise test to determine the lactate threshold (LT) and maximal oxygen uptake (V̇O2max). Results: LV circumferential strain at all levels, LV twist and torsion, LV late diastolic longitudinal strain rate, RV peak longitudinal strain and RV early and late diastolic longitudinal strain rate were all lower in athletes than controls. On multivariable linear regression only LV torsion (beta = −0.37, P = 0.03) had a significant association with LT. Only RV longitudinal late diastolic strain rate (beta = −0.35, P = 0.03) had a significant association with V̇O2max. Conclusions: This cohort of endurance athletes had lower LV circumferential strain, LV torsion and biventricular diastolic strain rates than controls. Increased LT, which is a major determinant of performance in endurance athletes, was associated with decreased LV torsion. Further work is needed to understand the mechanisms by which this occurs.

Background Cardiac biomarker release is ubiquitous following surgical and transcatheter aortic valve replacement (SAVR and TAVR), preventing accurate discrimination between release due to focal myocardial infarction (MI) and global myocardial injury. Cardiovascular magnetic resonance (CMR) late gadolinium enhancement imaging (LGE) is the most sensitive imaging method to detect post-procedural new MI. Our study aimed to compare rates of new MI using CMR LGE before and 6m after TAVR and SAVR.

BACKGROUND: Cardiac adaptation to aortic stenosis (AS) appears to differ according to sex, but reverse remodeling after aortic valve replacement has not been extensively described. The aim of the study was to determine using cardiac magnetic resonance imaging whether any sex-related differences exist in AS in terms of left ventricular (LV) remodeling, myocardial fibrosis, and reverse remodeling after valve replacement. METHODS: One hundred patients (men, n = 60) with severe AS undergoing either transcatheter or surgical aortic valve replacement underwent cardiac magnetic resonance scans at baseline and 6 months after valve replacement. RESULTS: Despite similar baseline comorbidity and severity of AS, women had a lower indexed LV mass than did men (65.3 ± 18.4 vs 81.5 ± 21.3 g/m(2), P < .001) and a smaller indexed LV end-diastolic volume (87.3 ± 17.5 vs 101.2 ± 28.6 mL/m(2), P = .002) with a similar LV ejection fraction (58.6% ± 10.2% vs 54.8% ± 12.9%, P = .178). Total myocardial fibrosis mass was similar between sexes (2.3 ± 4.1 vs 1.3 ± 1.1 g, P = .714), albeit with a differing distribution according to sex. After aortic valve replacement, men had more absolute LV mass regression than did women (18.3 ± 10.6 vs 12.7 ± 8.8 g/m(2), P = .007). When expressed as a percentage reduction of baseline indexed LV mass, mass regression was similar between the sexes (men 21.7% ± 10.1% vs women 18.4% ± 11.0%, P = .121). There was no sex-related difference in postprocedural LV ejection fraction or aortic regurgitation. Sex was not found to be a predictor of LV reverse remodeling on multiple regression analysis. CONCLUSIONS: There are significant differences in the way that male and female hearts adapt to AS. Six months after aortic valve replacement, there are no sex-related differences in reverse remodeling, but superior reverse remodeling in men as a result of their more adverse remodeling profile at baseline.

Background Extracellular volume (ECV) calculated from T1 maps can quantitatively characterize myocardial tissue, including the severity of tissue damage in myocardial infarction (MI) (1). An alternative approach for measuring the density of MI may be to calculate the relative signal intensity of LGE images.) A direct comparison of signal intensity of LGE and ECV in MI has not been carried out. We aimed to compare these two parameters in patients presenting with acute myocardial infarction.

Background Right ventricular function is of prognostic importance in a variety of clinical settings but its complex anatomic geometry can pose a challenge to 2-dimensional imaging modalities. Right ventricular dysfunction is thought to occur following cardiac surgery and independently predicts adverse outcomes. However a clear mechanism for this dysfunction remains undefined. We sought o accurately assess the effect of SAVR upon right ventricular function in patients treated for severe symptomatic aortic stenosis.

Background Diffuse myocardial fibrosis may be quantified with cardiovascular magnetic resonance (CMR) by calculating extra-cellular volume (ECV) from native and post-contrast T1 values. Previous studies have used either infusion or single bolus contrast administration. In clinical practice however split dose contrast injection is used as part of a stress/rest protocol in stress perfusion studies. The effects of using such an injection regime on ECV calculation is unknown. This study aimed to assess the effects of split dose versus single bolus contrast administration on ECV calculation.

Background Rheumatoid arthritis (RA) is a common autoimmune disease. Mortality is increased compared to the general population largely due to increased cardiovascular disease (CVD). Immune dysregulation and systemic inflammation are thought to be associated with this increased risk. CMR can provide an assessment of CVD, including myocardial and vascular morphology and function, but it is unknown which CMR measurements are most sensitive to detect early CVD. Objectives To determine CV manifestations of RA using CMR in newly diagnosed, treatment-naive patients compared with matched controls. Method Fifty-two RA patients fulfilling ACR/EULAR classification RA criteria, without CVD history, underwent CMR at 3.0T (Philips Achieva TX). They had symptoms for less than 1 year, had not yet received therapy with any disease modifying anti-rheumatic drugs, disease activity score (DAS28) ≥ 3.2 and at least one RA poor prognostic factor. 30 healthy controls were matched by age, sex and blood pressure. Standard balanced steady state free precession (SSFP) cine images were acquired and LV dimensions calculated. Strain analysis was performed by tissue-tagging using a spatial modulation of magnetization pulse sequence. For aortic distensibility (AD), multi-phase SSFP cine images (50 phases) were acquired in a plane transverse to the ascending aorta at the level of the pulmonary artery bifurcation. Aortic contours were drawn by manual planimetry of the endovascular–blood pool interface at the times of minimal and maximal distension. Native and 15 min post-contrast T1 maps were generated from mid-LV short axis using a modified 3,3,5 Look-Locker inversion sequence to calculate extra-cellular volume fraction (ECV). Results Participant characteristics are presented in Table 1. Aortic distensibility was reduced in RA patients compared to controls (mean±SD, 3.23 ± 1.6 10–3 mmHg-1 vs. 4.99 ± 1.8 10–3 mmHg-1, p = 0.001). Other measures of arterial stiffness including aortic stiffness index, compliance and strain showed differences with similar significance levels. Left ventricular remodelling was not different in the RA group compared with controls, but S’ was lower in RA (mean±SD, 0.99 ± 0.22 Seconds-1 vs. 1.13 ± 0.16 Seconds-1, p = 0.007) which may signify sub-clinical reduction in myocardial performance. Evidence for overt inflammation/fibrosis was seen in 4 patients with areas of focal non-ischaemic patterns of LGE, but native T1 and ECV was not different between the groups. See Table 2. Conclusion Early abnormal subclinical changes in vascular and myocardial function exist in newly diagnosed, treatment-naive RA patients, without overt changes in ventricular performance and geometry. The natural history of these observations and implications in the wider management of RA warrant further investigation.

Introduction Left bundle branch block (LBBB) is common following trans-catheter aortic valve implantation (TAVI) and has been linked to increased mortality, although whether this is due to the development of a TAVI-induced LBBB cardiomyopathy is unclear. Methods 48 patients undergoing TAVI for severe aortic stenosis were evaluated. 24 patients with TAVI-induced LBBB (LBBB-T) were matched with 24 patients with a narrow post-procedure QRS (nQRS). Patients underwent comprehensive Cardiovascular Magnetic Resonance (CMR) imaging prior to and 6m post-TAVI. Measured cardiac reverse remodelling parameters included left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and left sided chamber size. Inter and intraventricular dyssynchrony was determined using time to peak radial strain derived from CMR Feature Tracking. Results In the nQRS group there was no change in QRSd (93 ± 17 to 96 ± 11 ms, p = 0.098). In the LBBB-T group, QRSd increased by a mean of 55 ms from 96 ± 14 to 151 ± 12 (p= 18.6 ± 5.8 mm, p = 0.773). Post-procedure aortic regurgitant fraction was similar between groups (nQRS 5.4 ± 5.7 vs LBBB-T 5.5 ± 3.3%, p = 0.948). There was an inverse correlation between QRS duration and change in LVEF (r=-0.46, p = 0.001) and QRS duration and change in LV GLS (r=-0.37, p = 0.010). Conclusion LBBB-T is associated with less favourable cardiac reverse remodelling at medium term follow up. In view of this, every effort should be made to prevent TAVI-induced LBBB, especially as TAVI is extended to a younger, lower risk population.

Background Transcatheter aortic valve implantation is an established therapeutic option for patients with severe symptomatic aortic stenosis unsuitable for surgery. CMR has a lower intra-observer and inter-observer variability than echocardiography in the assessment of aortic regurgitation (AR), offering full volumetric quantitation independent of the number or eccentricity of regurgitant jets. Moderate AR following TAVI is an independent predictor of mortality in the postoperative period and has prompted development of novel bioprostheses designed to facilitate precise deployment and minimise paravalvular regurgitation (Figure 1). Aim To compare the degree of early post-procedure aortic regurgitation following implantation of the Medtronic CoreValve and Boston Scientific Lotus Valve systems in patients treated for severe symptomatic aortic stenosis. Methods All patients underwent an identical 1.5T CMR scan (Intera, Phillips Healthcare, Best, Netherlands) post-procedure prior to discharge. Through-plane phase contrast velocity encoded imaging was performed perpendicular to the aortic valve jet at a level above the aortic prosthesis. Aortic flow was subsequently quantified offline (QFlow version 7.2, Medis Medical Imaging Systems, Leiden, The Netherlands) and regurgitant fraction (%) derived. AR was defined as regurgitant fraction of none/trivial ≤ 5%, mild 6 – 15%, moderate 16 – 25%, moderate-severe 26 – 48%, and severe > 48% The invasive AR index derived at the time of TAVI was also recorded ([(Diastolic BP-LVEDP)/Systolic BP] x100). Results 18 Medtronic CoreValve patients (age 79.6 ± 6.3 years, 67% male, EuroSCORE II 4.59 ± 3.59%) and 24 Boston Lotus TAVI patients (age 78.6 ± 8.7years, 54% male, EuroSCORE II 4.07 ± 3.37%) were studied at a median interval of 6 days following implantation. The residual peak aortic pressure gradient observed following Boston Lotus implantation was higher than that following Medtronic CoreValve (25.8 ± 12.1 vs.15.0 ± 5.5mmHg, p = 0.001). The absolute regurgitant fraction was significantly lower following Boston Lotus implantation than following Medtronic CoreValve (Lotus: 4.0 ± 3.5% vs. CoreValve: 11.7 ± 7.2%, p = 0.001). The classification of AR severity is summarised in Figure 2. Overall, 39% of patients with CoreValve had moderate AR compared to no reported cases in the Lotus group. There was a negative correlation between invasive AR index and regurgitant fraction from CMR imaging (Spearman’s coefficient − 0.4, p = 0.016). Conclusions CMR directly quantifies AR following TAVI and there is agreement with invasive AR measurements. There was significantly less aortic regurgitation in the immediate post-implant period using the Boston Lotus valve compared with the Medtronic CoreValve. However the residual peak pressure gradient was lower with the Medtronic CoreValve. Further work is required to assess the longer term differences in AR and whether this translates into a mortality benefit.

Background NICE 2010 guidelines (CG95) proposed investigation according to pre-test likelihood (PTL) of coronary artery disease (CAD) in patients presenting with stable chest pain; low risk patients are referred for CT coronary angiography (CTCA), intermediate risk should have a functional test (stress echocardiography, MPS, CMR) with invasive angiography reserved for high risk patients and those with a PTL>90% having no investigation and treated prospectively as angina. The 2016 update to CG95 now recommends referral for CTCA in all patients with typical or atypical chest pain and in those with non-anginal pain but with ECG changes, with functional imaging reserved for those who have previously documented coronary disease or revascularisation. Our aim was to compare imaging resource utilisation between the 2010 and 2016 guideline recommendations to highlight the potential service implications if followed explicitly. Methods Consecutive patients referred over 4 weeks to the Leeds General Infirmary rapid access chest pain clinic (RACPC) with stable chest pain symptoms were prospectively evaluated. Non identifiable data was collected on demographics, typicality of chest pain symptoms and ECG findings and subsequently requested 1st line investigation. Patient notes were reviewed and PTL for patients was calculated in accordance with CG95 and hypothetical investigative strategies calculated according to both 2010 and 2016 guidelines. Results 157 consecutive patients were evaluated between 17th October and 17th November 2016. Patient demographics are displayed in table 1. 37 (23.5%) patients had typical angina, 55 (35.0%) had atypical angina, 65 (41.4%) had non-anginal symptoms. 16 (10.2%) patients had previous infarction/revascularisation. 25 (15.9%) patients had a PTL 90%. Table 2 shows diagnostic tests requested and hypothetical investigative strategies according to NICE 2010 CG95 and the 2016 update. Conclusion/Implications Our results show that if implemented in proposed 2016 form there will be a significant increase in the referral rate for CTCA with a corresponding decrease in referral for functional imaging and angiography. Furthermore the number of patients that are not investigated would more than double following the introduction of the proposed NICE 2016 guidelines. CTCA has high sensitivity for the diagnosis of CAD but more limited specificity and concerns are that increased usage in intermediate/high risk patients may lead to increased rates of unnecessary angiography due to the overestimation of severity of CAD. The change in guidelines would lead to a significant shift in practice that has implications for both workforce planning and provision of resources.

Background Prognosis and treatment of patients with chronic heart failure (CHF) differs according to whether it is ischaemic (ICM) or non-ischaemic cardiomyopathy (NICM). Multi-parametric cardiovascular magnetic resonance (CMR) can distinguish these aetiologies; strain imaging however may confer incremental diagnostic and prognostic information over left ventricular ejection fraction (LVEF). We hypothesised in a prospectively recruited sample of CHF patients, ICM and NICM have different myocardial strain patterns. Methods The VINDICATE trial investigated efficacy of high dose vitamin D in patients with CHF. A subgroup of the trial underwent CMR, blood and cardiopulmonary exercise tests at baseline. 53 patients (31 ICM, 22 NICM) underwent identical 3.0T CMR protocols (Achieva, Philips Healthcare, Best, The Netherlands). Tissue tagging by spatial modulation of magnetization (SPAMM) (spatial resolution 1.51 × 1.57×10mm3, tag separation 7 mm, 18 phases, typical TR/TE 5.8/3.5 ms, flip angle 10°, typical temporal resolution 55 ms) was acquired in short axis slices acquired at the apex, mid-ventricle, and base. Late gadolinium enhancement (LGE) was performed 15 min following administration of 0.15 mmol/kg gadolinium DTPA. CMR data were analysed quantitatively using commercially available software (CVI42, Circle Cardiovascular Imaging Inc. Calgary, Canada and inTag v1.0, CREATIS lab, Lyon, France). Endocardial and epicardial contours were drawn on SPAMM sequences using a semi-automated process. Peak circumferential LV strain (Ecc) was measured at apex, mid-ventricle, and base. LV twist was calculated by subtracting basal from apical rotation. Torsion was determined by: Torsion = Peak Twist x (Apical Radius+Basal Radius)/2xApex to Base length Results The two groups were comparable for baseline demographics (Table 1). The ICM group had significantly more prior revascularisation (CABG/PCI). There was no significant difference between the 2 groups in both LV dimensions and LVEF, however ICM had significantly more LGE (Table 2). There was no significant difference between the 2 groups in Ecc. NICM patients had significantly lower LV twist and torsion compared to the ICM group 6.0±3.68° vs 8.8±4.32° p=0.020 and 6.3±3.79° vs 8.8±4.69° p=0.048 respectively. Conclusion Despite similar EF and Ecc, patients with NICM had significantly less LV torsion than ICM. Myocyte dysfunction in ICM is more sub-endocardial due to the wave-front of ischaemia and more global in NICM. Relative perseveration of LV torsion of ICM over NICM is likely a result of sparing of sub-epicardial fibres and an increased compensatory recruitment of sub-epicardial fibres that are predominantly responsible for LV torsion. Recognition of different torsion patterns of ICM and NICM gives insight into aetiology of CHF, which may assist patient diagnosis and management, especially in those unable to have contrast agents.

Background Patients with type 2 diabetes and elevated urinary albumin:creatinine ratio (ACR) have increased risk of heart failure. We hypothesised this was due to cardiac tissue changes rather than silent coronary artery disease. Methods and results In a case-controlled observational study 130 subjects including 50 ACR+ve diabetes patients with persistent microalbuminuria (ACR >2.5 mg/mol in males and >3.5 mg/mol in females, ≥2 measurements, no previous renin angiotensin aldosterone (RAAS) therapy), 50 ACR-ve diabetes patients and 30 controls underwent cardiovascular magnetic resonance for investigation of myocardial fibrosis, ischaemia and infarction and echocardiography. 30 ACR+ve patients underwent further testing after 1 year treatment with RAAS blockade with ace inhibitor or angiotensin receptor blocker. Cardiac extracellular volume fraction (ECV), a measure of diffuse fibrosis, was higher in diabetes patients than controls (26.1±3.4 and 23.3%±3.0% p=0.0002) and in ACR+ve than ACR-ve diabetes patients (27.2±4.1 vs 25.1%±2.9%, p=0.004). ACR +ve patients also had lower E’ measured by echocardiography (8.2±1.9 vs. 8.9±1.9 cm/s, p=0.04) and elevated high-sensitivity cardiac troponin T (hs-cTnT) 18 vs 4%≥14 ng/L (p=0.05). Patients with elevated hs-cTnT had significantly elevated native T1 and ECV (1293.3±80.2 and 1235.8±46.5 ms, p=0.0001 and 30.3±4.8 vs. 25.6%±3.2%, p Treatment with RAAS inhibition was associated with a significant decrease in serum aldosterone level (337.0±192.7 to 244.3±137 pmol/L, p=0.03) but no significant change in 24 hour blood pressure. RAAS blockade was associated with increased left ventricular ejection fraction (59.3±7.8 to 61.5%±8.7%, p=0.03) and decreased ECV (26.5±3.6 to 25.2±3.1, p=0.01) but no changes in diastolic function or hs-cTnT levels. Conclusions Asymptomatic patients with type 2 diabetes and persistent microalbuminuria have several markers suggestive of diffuse cardiac fibrosis including elevated ECV, hs-cTnT and diastolic dysfunction. The prevalence of silent myocardial ischaemia or infarction was not influenced by ACR status. Treatment with an ACE inhibitor was associated with improvement in LV EF and ECV regression. These findings suggest that increased risk in this patient group is mediated by subclinical changes in tissue structure and function rather than occult CAD, which may have implications for the management of these patients.

Background The effect of transcatheter aortic valve replacement (TAVR) on very early left ventricular remodelling has not previously been evaluated. Left ventricular mass (LVM) regression at 30 days (assessed using echocardiography) has been linked to a 50% reduction in re-hospitalisation in the first year following TAVR. We sought to establish using cardiac magnetic resonance (CMR) imaging, the reference standard imaging technique for LVM quantification, whether LVM regression occurs very early following-TAVR. Methods 27 patients with symptomatic severe aortic stenosis undergoing TAVR were prospectively enrolled between June 2013 and April 2014. Patients with contraindications to CMR were excluded and all patients provided informed written consent. All patients underwent an identical 1.5T CMR protocol (Intera, Philips) prior to and at a median of 5 days following TAVR (IQR 2 days). Multislice, multi-phase cine imaging was carried out using a standard steady-state free procession pulse sequence in the short axis to cover the entire left ventricle. Quantitative analysis was performed using dedicated computer software (CVI 42 , Circle Cardiovascular Imaging, Alberta, Canada). LVM was calculated by the formula (epicardial volume – endocardial volume) x myocardial density (1.05 g/cm 3 ). Results Basic patient, echocardiographic and procedural characteristics can be seen in Table 1. At a median of 5 days following TAVR, mean LVM regressed by 12% from 129.5 +/- 32.5 g to 114.2+/-31 g and indexed LVM (LVMi) reduced from 69.4 ± 15.2 g/m 2 to 61.3 ± 15.1 g/m 2 (Figure 1). There was no significant change in indexed left ventricular diastolic volume (96.9 ± 24.5 to 96.8 ± 19.3 ml/m 2 , p = 0.79), LV ejection fraction (54.0 ± 14.6 to 58.4 ± 27.4%, p = 0.49) or indexed left atrial volume (71.5 ± 22.6 to 67.7 ± 22.1 ml/m 2 , p = 0.43). Mean LVM regression was similar between the Medtronic and Boston valve types (14.3 ± 10.4 gVs 16.5 ± 9.9 g, p = 0.58). There was no correlation between Valvulo-arterial impedance (ZVA) and LVM regression (r = 0.02, p = 0.93). There was no difference in mean LVMi regression according to gender (women 8.3 ± 2.8 g/m 2 Vs men 8.0 ± 5.7 g/m 2 , p = 0.83). TAVR valve size did not appear to impact on early LVM regression. LVMi regression was similar between those with a normal baseline LVM and those with an elevated baseline LVM (defined as 83 g/m 2 in men and 67 g/m 2 ) in women (7.8 ± 4.8 g Vs 9.0 ± 5.7 g, p = 0.60). 16 patients had evidence of late gadolinium enhancement (LGE) at baseline. There was a trend towards increased LVMi regression in those without LGE at baseline compared with those with LGE (10.1 ± 4.7 g/m 2 Vs 6.4 ± 4.7 g/m 2 , p = 0.07). Conclusions LVM regression begins very early following TAVR and occurs before changes in cavity size or ejection fraction which is likely to be a result of an immediate reduction in wall stress. The type of valve implanted does not appear to influence early LVM regression. Funding This study was part funded by the BHF (PG/11/126/29321).

Background Rheumatoid arthritis (RA) is associated with increased incidence of cardiovascular disease (CVD) and heart failure (HF) compared to the general population. CMR studies in the general population demonstrate that increases in left ventricular (LV) mass and early LV structural changes are predictors of HF in asymptomatic patients. Previous studies have reported conflicting data on LV geometry in heterogeneously sampled RA populations. Objectives To investigate the influence of disease duration on LV geometry using CMR by assessing and comparing two distinct RA populations; a well-defined population of newly diagnosed, treatment-naive RA and an established disease group. Method Seventy-five patients underwent CMR at 3.0T (Philips Achieva TX). None had known CVD or diabetes. 30 were RA patients fulfilling 2010 ACR/EULAR classification criteria, with symptoms for less than 1 year, no therapy with disease modifying anti-rheumatic drugs, disease activity score (DAS28) ≥3.2 and at least one poor RA prognostic factor. They were age-matched with 30 RA patients with disease duration >5 yrs. 15 healthy controls were age-matched. Standard balanced steady state free precession cine images were acquired and LV dimensions calculated offline. Tissue-tagging for strain analysis was acquired using a spatial modulation of magnetization pulse sequence. Results Participant characteristics can be seen in Table 1. Age, sex, blood pressure and body size were not different between the 3 groups. The established RA group had excellent disease control with median (IQR) CRP 0.0 mg/L (5.3) and DAS28 2.0 (1.7). CMR measurements are in Table 2. LV systolic performance, using LVEF and Ecc, was normal and similar in all groups. LV geometry was similar between early RA patients and healthy controls (p-values for LVEDV, LV Mass and LV Mass/LVEDV being 0.19, 0.51 and 0.11 respectively). Indexed LV mass and LV mass/LVEDV were lower in the established RA group compared to the early RA group (Mean±SD, 33 g ± 8/m 2 vs. 43 ± 9 g/m 2 , p Conclusion We compare two distinct RA populations and demonstrate that ventricular systolic performance (LVEF and Ecc) in the RA population is similar to controls of similar age. Abnormal LV geometry (LV mass and LVmass/EDV) is prevalent in asymptomatic patients with established RA. LV remodelling appears to occur despite excellent disease control, with the caveat that this is cross-sectional disease activity. These insights suggest that ventricular remodelling occurs later in RA and that CMR is a sensitive tool to detect such changes. Additional longitudinal evaluation can inform on the impact of inflammation/disease activity over time.

Introduction Aortic stenosis (AS) results in left ventricular hypertrophy, myocyte dysfunction and fibrosis as a physiological response to excessive afterload. Transcatheter Aortic Valve implantation (TAVI) is an effective treatment for severe AS, however controversy exists whether gender predisposes to improved myocardial function post procedure. Feature-tracking cardiovascular magnetic resonance (FT-CMR) is a novel method for quantification of myocardial strain and strain rate that can identify subtle changes in left ventricular (LV) mechanics prior to overt changes in LV ejection fraction (EF). Our aim was to compare the acute impact of TAVI on LV function between males and females defined by strain measurements. Methods 59 patients, 34 males and 25 females matched for age (78.4 ± 7.19 years vs 78.8 ± 9.7 years p = 0.876), EuroSCORE II (5.19 ± 4.33% vs 4.26 ± 2.99% p = 0.788) and presence of baseline myocardial fibrosis (p = 0.829) with severe, symptomatic AS were prospectively enrolled prior to TAVI. All patients underwent an identical 1.5T CMR protocol (Intera or Ingenia, Phillips Healthcare, Best, The Netherlands) at baseline and at a median of 4 days following TAVI. Endocardial and epicardial borders were traced manually on the end-diastolic slice, then strain and strain rate measurements were obtained using commercially available post-processing software (CVI42, Circle Cardiovascular Imaging, Calgary, Alberta, Canada). Results TAVI was associated with a significant and comparable reduction in peak aortic pressure gradient and LV mass index in both men and women (Table 1). There was no significant difference in extent of pressure drop (p = 0.374) or extent of regression of LV mass index (p = 0.095) between men and women. There was no significant change in left ventricular end diastolic volume indexed (LVEDVI) or LVEF observed acutely following TAVI, in men or women (Table 1). Longitudinal strain (Ell), circumferential strain (Ecc) and circumferential strain rate (SRcc) did not change significantly in men or women (Table 2). However, TAVI was associated with a significant increase in longitudinal strain rate (SRll) in males (p = 0.012) that was not observed in females (p = 0.184) (Table 2). Conclusion TAVI was associated with structural reverse remodelling that was comparable between males and females. Functional recovery in LV mechanics following TAVI may occur earlier in males than in females, although this may reflect the higher LVMI that men have at baseline prior to TAVI.

Introduction Cardiac biomarker release is ubiquitous following surgical and trans-catheter aortic valve replacement (SAVR and TAVI), preventing accurate discrimination between release due to focal myocardial infarction (MI) and global myocardial injury (Figure 1). Furthermore, the need for peri-procedural revascularisation in TAVI is debated. Cardiovascular magnetic resonance (CMR) late gadolinium enhancement imaging (LGE) is the most sensitive imaging method to detect post-procedural new MI. Our study aimed to compare rates of new MI using CMR LGE before and 6m after TAVI and SAVR. Methods Ninety six patients with severe aortic stenosis undergoing TAVI (n = 57) and SAVR (n = 39) were prospectively recruited and identical scans performed prior to (median 1 day) and 6m following aortic valve replacement. The presence of significant coronary artery disease (CAD) was determined by the occurrence of a >50% stenosis in any major epicardial vessel. Areas of LGE were quantified with computer-assisted planimetry (2SD; cmr 42 , Circle CVI). Presence of new LGE was determined by direct comparison of pre and post-procedure scans. Results The SAVR group was younger, less symptomatic, had less 3 vessel CAD and were at lower surgical risk than the TAVI group. Most (87%) SAVR implants were bioprosthetic and most TAVI implants were Medtronic CoreValve (79%) (86% Transfemoral). Thirty-four (60%) patients had non-revascularised CAD at the time of TAVI. MI pattern LGE was present at baseline in 24 TAVI (42%) and 9 SAVR (24%) patients. The rate of new MI was greater in the SAVR group than the TAVI group (SAVR, n = 10 (26%) vs. TAVI, n = 3 (5%), p = 0.004). Absolute mean mass of new MI was similar between groups (SAVR 1.1g ± 0.6g vs. TAVI 2.0g ± 1.4g, p = 0.395) as was infarct mass as a percentage of left ventricular mass (SAVR 1.0 ± 0.4% vs. TAVI 2.2 ± 1.3%, p = 0.268) (Figure 2). None of the SAVR and only one of the TAVI infarcts were detected clinically (Figure 1 – blue dot). 34 patients (60%) in the TAVI group had non-revascularised CAD at the time of TAVI, of whom only 3 (9%) had new MI. In the SAVR group, 16 patients (41%) underwent concurrent coronary artery bypass grafting (CABG). Patients undergoing CABG were less likely to have a new MI than those not requiring concurrent revascularisation (CABG 6.3% vs. no CABG 39.1%, p = 0.021). There was no difference in mean cardiopulmonary bypass time (New MI 88.5 ± 31.1 vs. No new MI 114.5 ± 47.4min, p = 0.112) and aortic cross clamp time according to LGE status (New MI 66 ± 25 vs. No New MI 84 ± 42min, p = 0.164). Conclusions MI is an infrequent complication of TAVI but is more common following SAVR. Infarct size is small following both procedures. The low new infarct rate in TAVI, especially in the context of high rates of non-revascularised CAD, is reassuring and strengthens the notion that coronary revascularization prior to TAVI may be unnecessary.

Introduction Left ventricular end-diastolic filling pressure (LVEDP) is an invasive measure of LV function obtained at cardiac catheterisation (CC) that predicts prognosis and guides therapeutic strategy. Echocardiographic E/E’ ratio has been shown to be inaccurate for estimation of LVEDP. Feature-tracking cardiovascular magnetic resonance (FT-CMR) is a novel method for quantification of myocardial deformation and can be used to quantitatively assess left atrial (LA) function. Currently there is no validated MRI parameter that estimates LVEDP. We hypothesised that LA strain correlates to LVEDP. Methods 14 patients in sinus rhythm, with severe AS underwent a 1.5T CMR protocol (Ingenia, Phillips Healthcare, Best, The Netherlands). LVEDP was recorded at the time of CC by standard techniques. 4 chamber and mid ventricular short axis steady state free procession cine images were obtained: LA endocardial and epicardial borders were traced manually on the end-diastolic slice and strain measurements were calculated using commercially available post-processing software (CVI42, Circle Cardiovascular Imaging, Calgary, Alberta, Canada). Results Patients were divided into 2 groups: low EDP (13 ± 2.4mmHg) and high EDP (36.1 ± 3.4mmHg) (p Conclusion LA function (PALS) as measured by FT-CMR is independently associated with LVEDP and may have a role in predicting LV filling pressures via a routine CMR protocol.

Cardiac rehabilitation is an evidence-based intervention which has evolved over time and incorporates physical, psycho-social and educational components with the aim of improving the patients' functioning following a cardiac event. The evidence base for cardiac rehabilitation following acute myocardial infarction has been growing over the past half a century. Individual randomized control trials were small and, therefore, mortality outcomes usually failed to reach significance; however, meta-analyses have proven consistently that participation in cardiac rehabilitation following a myocardial infarction is associated with a significant improvement in mortality. In the era of revascularization and improved drug therapies, observational studies still provide evidence that independent of other treatments, cardiac rehabilitation is a life-saving measure. Although early studies often only studied young males, more contemporary data include patients from all sectors of society and have found that groups such as women, the elderly and those with heart failure appear to have greater mortality benefits compared with the traditional young male cohort. Uptake remains a problem and one challenge for the future is ensuring improved uptake on to good-quality rehabilitation programmes and demonstrating these positive effects.

Background Giant cell arteritis (GCA) is the commonest primary systemic vasculitis affecting older people. Dilatation of the aorta may occur as a late complication and is believed to arise from damage to the aortic wall from inflammation. Objectives To determine the prevalence of thoracic aortic dilatation and assess aortic stiffness by CMR in patients with GCA diagnosed at least 2 years previously. Method Consecutive patients recruited to the UK GCA Consortium study were invited. 49 patients (median disease duration 4.5 years) underwent CMR at 3.0T (Philips Achieva TX). Cine images were acquired to measure the diameter of the ascending aorta (AsAo) and descending aorta (DsAo) at the level of the main pulmonary artery (MPA) and aortic arch from luminal edge-to-edge. Aortic stiffness was assessed by aortic distensibility (AD) and pulse-wave velocity (PWV). For AD, cine images (50 phases) were acquired in a plane transverse to AsAo at the level of MPA. Aortic contours were drawn manually at the times of minimal/maximal distension. For PWV, through-plane phase contrast velocity mapping was performed perpendicular to AsAo/DsAo at the level of MPA. Velocity-time curves were derived and the distance between the two locations measured to calculate PWV using the transit-time method. Results Patient characteristics: Mean age 73 ± 6 years, female gender 35 (71%), biopsy-positive 31 (63%), body surface area (BSA) 1.8 ± 0.2 m 2 , systolic blood pressure (BP) 148 ± 20 mmHg, pulse pressure 75 ± 21 mmHg. CMR measurements in Table 1. 30 (61%) patients had dilated thoracic aortas – corrected to BSA and applied to CMR nomograms [Davis et al . 2014. JCMR 16(1):9]. 5 (10%) patients had dilated AsAo at surgical intervention thresholds according to AHA/ACC guidelines. Aortic stiffness was increased with lower AD (median [IQR] 0.9 [0.8]10–3 mmHg -1 ) and higher PWV (11 ± 3 m/s) than normal ranges Aquaro et al . 1 Disease duration did not correlate with aortic measurements. 10/11 biopsy-negative and 17/31 biopsy-positive patients had dilated aortas. Age, body mass index (BMI) and BP were similar between dilated and non-dilated aorta groups. There was a female to male preponderance in the dilated group (26/35 vs. 4/30 respectively, P Conclusion Dilatation of the thoracic aorta and arterial stiffness are common in patients with GCA. There is female preponderance in dilatation without differences in basic demographics. In biopsy-negative patients, under-treatment and/or variability in phenotype could explain increased aortic dilatation. Further investigation will be required to evaluate the effect of severity, treatment length/type, disease duration and cardiovascular risk factors on aortic morphology and function. Reference Aquaro, et al .Observational study of regional aortic size referenced to body size: productionof a cardiovascular magnetic resonance nomogram Davis et al. J Cardiovasc MagnReson 2014; 16 :9, doi:10.1186/1532-429X-16-9