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Objectives The authors explored the development and validation of machine-learning models for augmenting the echocardiographic grading of aortic stenosis (AS) severity. Background In AS, symptoms and adverse events develop secondarily to valvular obstruction and left ventricular decompensation. The current echocardiographic grading of AS severity focuses on the valve and is limited by diagnostic uncertainty. Methods Using echocardiography (ECHO) measurements (ECHO cohort, n = 1,052), we performed patient similarity analysis to derive high-severity and low-severity phenogroups of AS. We subsequently developed a supervised machine-learning classifier and validated its performance with independent markers of disease severity obtained using computed tomography (CT) (CT cohort, n = 752) and cardiovascular magnetic resonance (CMR) imaging (CMR cohort, n = 160). The classifier’s prognostic value was further validated using clinical outcomes (aortic valve replacement [AVR] and death) observed in the ECHO and CMR cohorts. Results In 1,964 patients from the 3 multi-institutional cohorts, 1,346 (68%) subjects had either nonsevere or discordant AS severity. Machine learning identified 1,117 (57%) patients as having high-severity and 847 (43%) as having low-severity AS. High-severity patients in CT and CMR cohorts had higher valve calcium scores and left ventricular mass and fibrosis, respectively than the low-severity group. In the ECHO cohort, progression to AVR and progression to death in patients who did not receive AVR was faster in the high-severity group. Compared with the conventional classification of disease severity, machine-learning–based severity classification improved discrimination (integrated discrimination improvement: 0.07; 95% confidence interval: 0.02 to 0.12) and reclassification (net reclassification improvement: 0.17; 95% confidence interval: 0.11 to 0.23) for the outcome of AVR at 5 years. For both ECHO and CMR cohorts, we observed prognostic value of the machine-learning classifications for subgroups with asymptomatic, nonsevere or discordant AS. Conclusions Machine learning can integrate ECHO measurements to augment the classification of disease severity in most patients with AS, with major potential to optimize the timing of AVR.

International audience; Atrial fibrillation is the most common cause of arrhythmia which is responsible for over 15% of ischemic strokes, most of these being secondary to migration of a left atrial appendage (LAA) thrombus. In patient with contraindication to anticoagulant therapy, percutaneous closure system placement may be indicated. Cardiac computed tomography (CT) angiography plays a central role in the initial assessment as well as in the follow-up. The purpose of the pre-implantation cardiac CT angiography is to evaluate the anatomy of the LAA in order to select the most suitable prosthesis and check for any contraindication to device implantation. Image analysis is divided into four steps that include analysis of the approach; search for a thrombus in the LAA; investigation of the anatomy of the LAA (morphology of the LAA, dimensions of the LAA and choice of device) and cardiac and thoracic assessments. Follow-up involves CT examination to check for correct placement of the device and to detect any complications. On the basis of the results of currently available published research, a panel of experts has issued recommendations regarding cardiac CT angiography prior to percutaneous LAA closure device placement, which were further endorsed by the Société française d'imagerie cardiaque et vasculaire diagnostique et interventionnelle (SFICV).

Aim: to investigate the factors implied in the development of postoperative complications in both self-expandable and balloon-expandable transcatheter heart valves by means of finite element analysis (FEA). Materials and methods: FEA was integrated into CT scans to investigate two cases of postoperative device failure for valve thrombosis after the successful implantation of a CoreValve and a Sapien 3 valve. Data were then compared with two patients who had undergone uncomplicated transcatheter heart valve replacement (TAVR) with the same types of valves. Results: Computational biomechanical modeling showed calcifications persisting after device expansion, not visible on the CT scan. These calcifications determined geometrical distortion and elliptical deformation of the valve predisposing to hemodynamic disturbances and potential thrombosis. Increased regional stress was also identified in correspondence to the areas of distortion with the associated paravalvular leak. Conclusion: the use of FEA as an adjunct to preoperative imaging might assist patient selection and procedure planning as well as help in the detection and prevention of TAVR complications.

International audience; This paper is intended to update the former consensus between the French Societies of Radiology and Cardiology about the use of stress cardiac magnetic resonance imaging in chronic coronary syndrome, published in 2009. The Delphi method was used to build the present consensus. This expert panel consensus includes recommendations for indications, the procedure (with patient preparation), stress-inducing drugs, the acquisition protocol, interpretation and risk stratification by stress magnetic resonance imaging.

International audience; This position paper was intended to update the former consensus between the French Societies of Radiology and Cardiology about the use of stress cardiac magnetic resonance imaging (MRI) in chronic coronary syndrome published in 2009. The Delphi method was used to build the present consensus. This expert panel consensus includes recommendations for indications, procedure with patient preparation, stress inducing drugs, acquisition protocol, interpretation and risk stratification by stress MRI.

Gated computed tomography (CT) might not adequately predict occurrence of post-implantation transcatheter aortic valve replacement (TAVR) complications in hostile aortic root as it would require a more complex integration of morphological, functional and hemodynamical parameters. We used a computational framework based on finite element analysis (FEA) to simulate patient-specific implantation. Application of biomechanical modelling using FEA to gated-CT was able to demonstrate the relation of the device with voluminous calcification, its consequent misalignment and a significant stent deformation. Use of FEA and other advanced computed predictive modelling techniques as an adjunct to CT scan could improve our understanding of TAVR, potentially predict complications and fate of the devices after implantation and inform patient-specific treatment.

An increased acceleration time to ejection time (AT/ET) ratio is associated with increased mortality in patients with aortic stenosis (AS).To identify the factors associated with an increased AT/ET ratio.The relationships between the AT/ET ratio and clinical and Doppler echocardiographic variables of interest in the setting of AS were analysed retrospectively in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (LVEF). The computed tomography aortic valve calcium (CT-AVC) score was studied in a subgroup of 342 patients.In the univariate analysis, the AT/ET ratio was found to correlate with peak aortic jet velocity (r=0.57; P0.0001), mean pressure gradient (r=0.60; P0.0001), aortic valve area (r=-0.50; P0.0001) and CT-AVC score (r=0.24; P0.0001). The AT/ET ratio had good accuracy in predicting a peak aortic jet velocity≥4 m/s, a mean pressure gradient≥40mmHg and an aortic valve area≤1.0cmThe AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond the haemodynamic and anatomical severity of AS influence the AT/ET ratio, including LV geometry, function and systolic blood pressure. These findings should be considered when assessing the AT/ET ratio in patients with AS and preserved LVEF.

Background Acceleration time to ejection time ratio (AT/ET) prolongation is associated with increased mortality in patients with aortic stenosis (AS). Purpose To identify the determinants associated with increased AT/ET. Methods The relationships between AT/ET ratio, clinical and Doppler echocardiographic variables of interest in the setting of AS were studied in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (EF), with Computed Tomography – Aortic Valve Calcium (CT-AVC) score studied in a subgroup of 342 patients. Results In univariate analysis, AT/ET ratio did correlate with aortic peak velocity (Vmax, r=0.57, p Conclusion AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond hemodynamic and anatomic severity of AS influence AT/ET ratio including LV geometry, function and SBP. These findings should be considered when assessing AT/ET in patients with AS and preserved LVEF. Acknowledgement/Funding Local funding

Aims Early diagnosis of cardiac involvement is a key issue in the management of AL amyloidosis. Our objective was to establish a diagnostic score of cardiac involvement in AL amyloidosis and to compare it with the current consensus criteria [i.e. left ventricular hypertrophy >12 mm and N-terminal pro b-type natriuretic peptide (NT-proBNP) >332 ng/L]. Methods and results We carried out a prospective and multicenter study on AL amyloidosis patients who underwent cardiac evaluation including clinical examination, electrocardiography (ECG), cardiac biomarkers, transthoracic echocardiography (TTE), and cardiac magnetic resonance imaging (CMR). Cardiac involvement was based on CMR and/or endomyocardial biopsy. In a derivation cohort of 114 patients (82 with cardiac involvement), the highest diagnostic accuracy was observed with NT-proBNP and troponin blood levels, TTE-derived global longitudinal strain (LS), and apical to basal LS gradient. By using multivariate analysis, we established a diagnostic score including global LS ≥−17% (1 point), apical/(basal + median) LS ≥0.90 (1 point), and troponin T >35 ng/L (1 point). A score >1 was associated with sensitivity of 94% and specificity of 97%, an area under the curve of 0.98 [95% confidence interval (CI) 0.93–0.99] as well as a net reclassification index of 0.39 (95% CI 0.28–0.46) when compared with consensus criteria. In a validation cohort of 73 AL amyloidosis patients, the area under the receiver operating characteristic curve of the diagnostic score was 0.97 (95% CI 0.90–0.99). Conclusion Combining T troponin blood levels and two echo-derived strain parameters leads to very high accuracy for diagnosing cardiac involvement in AL amyloid patients.

Aims Coronary computed tomography angiography (CTA) has emerged as a non-invasive diagnostic method for patients with suspected coronary artery disease, but its usefulness in patients with complex coronary artery disease remains to be investigated. The present study sought to determine the agreement between separate heart teams on treatment decision-making based on either coronary CTA or conventional angiography. Methods and results Separate heart teams composed of an interventional cardiologist, a cardiac surgeon, and a radiologist were randomized to assess the coronary artery disease with either coronary CTA or conventional angiography in patients with de novo left main or three-vessel coronary artery disease. Each heart team, blinded for the other imaging modality, quantified the anatomical complexity using the SYNTAX score and integrated clinical information using the SYNTAX Score II to provide a treatment recommendations based on mortality prediction at 4 years: coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or equipoise between CABG and PCI. The primary endpoint was the agreement between heart teams on the revascularization strategy. The secondary endpoint was the impact of fractional flow reserve derived from coronary CTA (FFRCT) on treatment decision and procedural planning. Overall, 223 patients were included. A treatment recommendation of CABG was made in 28% of the cases with coronary CTA and in 26% with conventional angiography. The agreement concerning treatment decision between coronary CTA and conventional angiography was high (Cohen’s kappa 0.82, 95% confidence interval 0.74–0.91). The heart teams agreed on the coronary segments to be revascularized in 80% of the cases. FFRCT was available for 869/1108 lesions (196/223 patients). Fractional flow reserve derived from coronary CTA changed the treatment decision in 7% of the patients. Conclusion In patients with left main or three-vessel coronary artery disease, a heart team treatment decision-making based on coronary CTA showed high agreement with the decision derived from conventional coronary angiography suggesting the potential feasibility of a treatment decision-making and planning based solely on this non-invasive imaging modality and clinical information. Trial registration number NCT02813473.

Background— Computed tomography aortic valve calcium scoring (CT-AVC) holds promise for the assessment of patients with aortic stenosis (AS). We sought to establish the clinical utility of CT-AVC in an international multicenter cohort of patients. Methods and Results— Patients with AS who underwent ECG-gated CT-AVC within 3 months of echocardiography were entered into an international, multicenter, observational registry. Optimal CT-AVC thresholds for diagnosing severe AS were determined in patients with concordant echocardiographic assessments, before being used to arbitrate disease severity in those with discordant measurements. In patients with long-term follow-up, we assessed whether CT-AVC thresholds predicted aortic valve replacement and death. In 918 patients from 8 centers (age, 77±10 years; 60% men; peak velocity, 3.88±0.90 m/s), 708 (77%) patients had concordant echocardiographic assessments, in whom CT-AVC provided excellent discrimination for severe AS (C statistic: women 0.92, men 0.89). Our optimal sex-specific CT-AVC thresholds (women 1377 Agatston unit and men 2062 Agatston unit) were nearly identical to those previously reported (women 1274 Agatston unit and men 2065 Agatston unit). Clinical outcomes were available in 215 patients (follow-up 1029 [126–2251] days). Sex-specific CT-AVC thresholds independently predicted aortic valve replacement and death (hazard ratio, 3.90 [95% confidence interval, 2.19–6.78]; P P =0.010). Conclusions— Sex-specific CT-AVC thresholds accurately identify severe AS and provide powerful prognostic information. These findings support their integration into routine clinical practice. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifiers: NCT01358513, NCT02132026, NCT00338676, NCT00647088, NCT01679431.

Background The role of 256 slices coronary computed tomography angiography (CCTA) one-beat acquisition in the evaluation of coronary arteries is well established, but the volume of the contrast media (CM) is a serious limitation of using this method in patients with severe comorbidities, specially in renal insufficiency. Reducing the dose of contrast would allow to expand indications to CCTA by reducing side effects of CM administration. Purpose To minimize contrast media volume in cardiac CT one-beat acquisition by optimizing injection protocols with maintaining the high image quality. Methods In total, 204 consecutive patients were enrolled and scanned on a 256-slices CT one-beat acquisition with standard tube voltage 120 kV. Patients were divided into two groups according to the injection protocols. Group A was scanned by using a standard three-phase injection protocol by using smart shot dual injector. Patients of group B underwent a new three-phase injection protocol with 63% CM dose reduction. Attenuation, image noise, signal-to-noise ratio (SNR) were calculated. Image quality was evaluated using 4-point Likert scale. Results The mean age was 61,5 ± 12,2, and 50,5% were males. The body mass index (BMI) was significantly lower in group B (28,1 ± 5,3 kg/m 2 vs. 24,4 ± 2,9 kg/m 2 respectively, P Mean amount of CM of group B was lowered by 63,1% on average when compared to group A (75,5 ± 4,7 ml in group A and 27,8 ± 5,6 ml in group B, P There were no significant differences in SNR (15,7 ± 3,4 vs. 14,9 ± 6,4, P = 0,704) as well as in image quality between groups (3,8 ± 0,4 vs. 3,8 ± 0,37, P = 0,85). Conclusion CCTA one-beat acquisition by using new injection protocol with 63% contrast media dose reduction maintain the high image quality of coronary arteries in patient with normal BMI. This 2,7 times contrast dose reduction opens the door and expands the boundaries for cardiac CT in patients with multiple comorbidities and renal insufficiency.

International audience; Background: Patients with Cushing's syndrome have left ventricular (LV) hypertrophy and dysfunction on echocardiography, but echo-based measurements may have limited accuracy in obese patients. No data are available on right ventricular (RV) and left atrial (LA) size and function in these patients.Objectives: The objective of the study was to evaluate LV, RV, and LA structure and function in patients with Cushing's syndrome by means of cardiac magnetic resonance, currently the reference modality in assessment of cardiac geometry and function.Methods: Eighteen patients with active Cushing's syndrome and 18 volunteers matched for age, sex, and body mass index were studied by cardiac magnetic resonance. The imaging was repeated in the patients 6 months (range 2-12 mo) after the treatment of hypercortisolism.Results: Compared with controls, patients with Cushing's syndrome had lower LV, RV, and LA ejection fractions (P < .001 for all) and increased end-diastolic LV segmental thickness (P < .001). Treatment of hypercortisolism was associated with an improvement in ventricular and atrial systolic performance, as reflected by a 15% increase in the LV ejection fraction (P = .029), a 45% increase in the LA ejection fraction (P < .001), and an 11% increase in the RV ejection fraction (P = NS). After treatment, the LV mass index and end-diastolic LV mass to volume ratio decreased by 17% (P < .001) and 10% (P = .002), respectively. None of the patients had late gadolinium myocardial enhancement.Conclusion: Cushing's syndrome is associated with subclinical biventricular and LA systolic dysfunctions that are reversible after treatment. Despite skeletal muscle atrophy, Cushing's syndrome patients have an increased LV mass, reversible upon correction of hypercortisolism.

Using coronary computed tomography angiography (CCTA), severe coronary calcification hampers visual assessment due to the blooming artefact. Calcifications have been associated with discrepancy between non-invasive and invasive luminal evaluation. Moreover, the presence of severe calcification

Introduction Acceleration time to ejection time ratio (AT/ET) prolongation is associated with increased mortality in patients with aortic stenosis (AS). We aimed at evaluating the determinants associated with increased AT/ET. Method The relationships between AT/ET ratio, clinical and Doppler echocardiographic variables of interest in the setting of AS were studied in 1107 patients with AS and preserved left ventricular (LV) ejection fraction (EF), with Computed Tomography–Aortic Valve Calcium (CT-AVC) score studied in a subgroup of 342 patients. Results In univariate analysis, AT/ET ratio did correlate with aortic peak velocity (Vmax, r = 0.57, P Conclusion AT/ET ratio is related to echocardiographic and CT-AVC indices of AS severity. However, multiple intricate factors beyond hemodynamic and anatomic severity of AS influence AT/ET ratio including LV geometry, function and SBP. These findings should be considered when assessing AT/ET in patients with AS and preserved LVEF.

IntroductionTo evaluate feasibility, image quality and radiation dose of CCTA in patients with atrial fibrillation (AF) using a new generation 256-MDCT.Methods and materialsThirty consecutive patients (mean HR 103.8±52.2 bpm) with AF underwent CCTA on a 256-MDCT (Revolution CT, General Electric). Prevalence and impact on diagnosis of motion and step artifacts were independently evaluated by two experienced readers using a 3-point scale (0: no artifact; 1: artifacts without interference on diagnosis; 2: artifacts interfere with diagnosis) and percentage of assessable coronary segments was calculated. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were measured for quantitative assessment. Radiation dose was evaluated by calculating the mean effective dose (ED).ResultsOn a per-patient analysis, all the coronary segments were assessable in 28 (93%) patients. Only 3 coronary segments were not assessable in 2 patients due to motion artefacts resulted in a coronary segments assessability of 99.3% (453/456 segments) in the overall population. No step artifact was observed whereas motion artefacts (3-point scale score of 0.53±0.6) were infrequent and do not interfere with diagnosis. The mean CNR and mean SNR were respectively 13.3±4.6 and 13.0±3.3. ED remains low with an average of 3.3±2.5 mSv.ConclusionCCTA is feasible in AF patients using a new generation 256-MDCT providing good image quality and low radiation dose in this challenging population.

Introduction To evaluate feasibility, image quality and radiation dose of CCTA in obese patients using new generation 256-MDCT. Methods and materials Thirty consecutive obese patients (Body Mass Index (BMI)>30) undergoing CCTA on a 256-MDCT (Revolution CT, General Electric) were retrospectively included. Prevalence and impact on diagnosis of motion and step artifacts were independently evaluated by two experienced readers using a 3-point scale (0: no artifact; 1: artifacts without interference on diagnosis; 2: artifacts interfere with diagnosis) and percentage of assessable coronary segments was calculated. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were measured for quantitative assessment. Radiation dose was evaluated by calculating the mean effective dose (ED). Results Mean BMI was 36.0±5.9kg/m 2 with a mean HR of 91.4.0±48.9 bpm. Mean injected contrast volume (Iohexol 350) was 73.0±11.2mL. On a per-patient analysis, all the coronary segments were assessable in 29 (97%) patients. Only 2 coronary segments were not assessable in 1 patient due to motion arte-facts resulted in a coronary segments assessability of 99.6% (455/457 segments) in the overall population. No step artifact was observed whereas motion arte-facts (3-point scale score of 0.27±0.9) were infrequent and do not interfere with diagnosis. The mean CNR and mean SNR were respectively 10.0±2.6 and 11.1±2.0. ED remains low with an average of 2.71±1.6 mSv. Conclusion CCTA is feasible in obese patients using a new generation 256-MDCT providing good image quality and low radiation dose in this challenging population.

Background— Real-time 3-dimensional echocardiography (RT3DE) is superior to 2D echocardiography in assessing left ventricular (LV) volumes and ejection fraction (EF), but its feasibility is limited by multibeat acquisition, which requires an optimal breath-hold and a regular heart rhythm. We sought to evaluate the accuracy and feasibility of single- and 2-beat RT3DE for LV volume and EF assessment. Methods and Results— Sixty-six consecutive patients referred for cardiac magnetic resonance (CMR) underwent RT3DE and CMR on the same day. Of the 50 patients (age, 59±18 years; 68%men; 42% coronary artery disease; LVEF=49±14%; limits, 14% to 76%) with an adequate RT3DE image quality, accuracy for LV volumes and EF measurements of single- and 2-beat modalities were compared with the conventional 4-beat acquisition and CMR. Correlations with CMR for LV end-diastolic volume (161±59 mL, r =0.93 to 0.94) and end-systolic volume (86±56 mL, r =0.93 to 0.96) were excellent regardless of the number of cardiac cycles used. However, because of the low temporal resolution (7±2 volumes per second), single-beat underestimated LVEF (bias, −5±8%) with greater bias than 2-beat (bias, 1±6%, P P Conclusions— Compared with conventional multibeat acquisitions, 2-beat modality provides similar accuracy in LV volume and EF measurements and should be preferred due to fewer stitching artifacts. In contrast, the temporal resolution of single-beat modality appears insufficient to provide an accurate estimation of LVEF.

Background The clinical significance of moderate coronary stenosis is a fundamental to the choice of treatment. The gold standard is invasive fractional flow reserve (FFR) studying by quantitative coronary angiography (QCA). The role of 256 slices coronary computed tomography angiography (CCTA) one-beat acquisition is insufficiently studied and may be an important factor to predict the clinical significance of moderate coronary stenosis. Purpose To identify morphological CCTA predictors for the clinical significance of moderate coronary artery stenosis. Methods A total of 61 arteries (43 consecutive patients) underwent CCTA and QCA associated with a lesion-specific FFR measurement were retrospectively analyzed. CCTA was performed on a 256-slices CT one-beat acquisition, three-phase injection protocol by using smart shot dual injector. Stenosis from 50–69% were considered as moderate. FFR ≤ 0.80 was considered as functionally significant. Results The mean age was 67.9 ± 10.1, BMI 27.3 ± 4.4 kg/m2 and 75% were males. Twenty-nine percent patients (18 arteries) have clinically significant moderate stenosis with FFR ≤ 0.8; 23% (n = 14) have moderate but not clinically significant stenosis (FFR > 0.80) and 48% (n = 29) were presented by 30–49% stenosis. All of stenosis 0.8 (P Conclusion CCTA plays an important role for noninvasive assessment of clinical significance of moderate coronary stenosis. Moderate stenosis are clinically significant (FFR ≤ 0.8) if their length is more than 16 mm in calcified arteries, particularly in culprit arteries with multiple stenosis.

The aim of this study is to quantify aortic backward flow (BF) using phase-contrast cardiovascular magnetic resonance (PC-CMR) and to study its associations with age, indexes of arterial stiffness, and geometry. Although PC-CMR blood flow studies showed a simultaneous presence of BF and forward flow (FF) in the ascending aorta (AA), the relationship between aortic flows and aging as well as arterial stiffness and geometry in healthy volunteers has never been reported. We studied 96 healthy subjects [47 women, 39 ± 15 yr old (19–79 yr)]. Aortic stiffness [arch pulse wave velocity (PWVAO), AA distensibility], geometry (AA diameter and arch length), and parameters related to AA BF and FF (volumes, peaks, and onset times) were estimated from CMR. Applanation tonometry carotid-femoral pulse-wave velocity (PWVCF), carotid augmentation index, and time to return of the reflected pressure wave were assessed. Whereas FF parameters remained unchanged, BF onset time shortened significantly ( R2 = 0.18, P < 0.0001) and BF volume and BF-to-FF peaks ratio increased significantly ( R2 = 0.38 and R2 = 0.44, respectively, P < 0.0001) with aging. These two latter BF indexes were also related to stiffness indexes (PWVCF, R2 > 0.30; PWVAO, R2 > 0.24; and distensibility, R2 > 0.20, P < 0.001), augmentation index ( R2 > 0.20, P < 0.001), and aortic geometry (AA diameter, R2 > 0.58; and arch length, R2 > 0.31, P < 0.001). In multivariate analysis, aortic diameter was the strongest independent correlate of BF beyond age effect. In conclusion, AA BF estimated using PC-CMR increased significantly in terms of magnitude and volume and appeared earlier with aging and was mostly determined by aortic geometry. Thus BF indexes could be relevant markers of subclinical arterial wall alterations.

A 28-year-old immunocompetent man coming back from Brazil was admitted to the coronary care unit after an episode of syncope without chest pain, vomiting, or other symptoms. Physical examination revealed bradycardia and splenomegaly without fever. The ECG showed a complete atrioventricular (AV) block with ventricular escape rhythm at 38 bpm (Figure 1). Biology showed mild elevation of cardiac troponin Ic at 0.7 ng/mL (normal range

Purpose: Diagnosis and management of thoracic aorta (TA) disease demand the assessment of accurate quantitative information of the aortic anatomy. We investigated the principal modes of variation in aortic 3-dimensional geometry paying particular attention to the curvilinear portion. Materials and Methods: Images were obtained from extended noncontrast multislice computed tomography scans, originally intended for coronary calcium assessment. The ascending, arch, and descending aortas of 500 asymptomatic patients (57±9 y, 81% male) were segmented using a semiautomated algorithm that sequentially inscribed circles inside the vessel cross-section. Axial planes were used for the descending aorta, whereas oblique reconstructions through a toroid path were required for the arch. Vessel centerline coordinates and the corresponding diameter values were obtained. Twelve size and shape geometric parameters were calculated to perform a principal component analysis. Results: Statistics revealed that the geometric variability of the TA was successfully explained using 3 factors that account for ∼80% of total variability. Averaged aortas were reconstructed varying each factor in 5 intervals. Analyzing the parameter loadings for each principal component, the dominant contributors were interpreted as vessel size (46%), arch unfolding (22%), and arch symmetry (12%). Variables such as age, body size, and risk factors did not substantially modify the correlation coefficients, although some particular differences were observed with sex. Conclusions: We conclude that vessel size, arch unfolding, and symmetry form the basis for characterizing the variability of TA morphology. The numerical data provided in this study as supplementary material can be exploited to accurately reconstruct the curvilinear shape of normal TAs. Fil: Casciaro, Mariano Ezequiel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Favaloro. Facultad de Ingeniería y Ciencias Exactas y Naturales; Argentina Fil: Craiem, Damian. Universidad Favaloro. Facultad de Ingeniería y Ciencias Exactas y Naturales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Chironi, Gilles. Universite de Paris V; Francia Fil: Graf Caride, Diego Sebastián. Universidad Favaloro. Facultad de Ingeniería y Ciencias Exactas y Naturales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Macron, Laurent. Universite de Paris V; Francia Fil: Mousseaux, Elie. Universite de Paris V; Francia Fil: Simon, Alain. Universite de Paris V; Francia Fil: Armentano, Ricardo Luis. Universidad Favaloro. Facultad de Ingeniería y Ciencias Exactas y Naturales; Argentina

Background Diastolic dysfunction evaluation may be relevant for early diagnosis of hypertrophic cardiomyopathy (HCM) and subsequent risk assessment. The aim of our study was to assess phase contrast cardiac magnetic resonance (PCCMR) diastolic parameters obtained with a semi-automated method in relation to left ventricular (LV) remodeling and late gadolinium enhancement (LGE) in patients with HCM. Methods We studied 48 patients with HCM and 23 healthy volunteers matched for age, sex and body surface area (BSA). Mitral inflow and myocardial velocities were assessed using through plane 2D PC-CMR (VENC=150cm/s and 20cm/s respectively). Transmitral peak flow-rates (Ef and Af) and early E’ peak myocardial longitudinal velocity were obtained semi-automatically using CardFlow (INSERM U678). LV volumes, segmental thickness and mass were obtained from SSFP images. LGE volume was quantified semi-automatically using a 6 SD threshold. Results Peak myocardial longitudinal velocity E’ was significantly lower and E/E’ was significantly higher in patients with HCM compared with controls (Table). We found a linear relationship between decreased E’ and increased LV mass index (p

Background The choice of post contrast acquisition time is crucial to optimize T1 mapping. Indeed, equilibrium is required for a reliable characterization of interstitial myocardial fibrosis. The majority of studies regarding T1 equilibrium were performed on healthy subjects. Accordingly, the aims of our study were 1) to assess post-contrast T1 Kinetics in HCM patients, in comparison to healthy volunteers, and 2) to determine acquisition times that enable a better differentiation between the two groups.

PurposeTo evaluate the benefits regarding image quality and radiation dose of new generation 256 Multi-Detector CT (MDCT) for CCTA in patients with a high heart rate (HR).MethodsHundred consecutive patients with a HR>65bpm were retrospectively included (50 patients on a 64-MDCT, group A, 73.9±7.5 bpm; 50 patients on a 256-MDCT, group B, 85.8±30.0bpm). Prevalence and impact on diagnosis of motion and step artifacts were evaluated by two experienced readers using a 3-point scale (0: no artifact; 1: artifacts without interference on diagnosis; 2: artifacts interfere with diagnosis) and percentage of assessable coronary segments was calculated. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were measured for quantitative assessment. Radiation dose was evaluated by calculating the mean effective dose (ED).ResultsIn group B, motion artefacts were significantly reduced (0.58±0.64 vs 1.37±0.72, p

Global longitudinal strain (GLS) and basal longitudinal strain (BLS) assessed using two-dimensional speckle-tracking imaging have been proposed as subtle markers of left ventricular (LV) systolic dysfunction with potential prognostic value in patients with aortic stenosis (AS). The aim of this study was to evaluate the relationship between longitudinal strain and symptomatic status in patients with AS.GLS and BLS were measured in 171 patients with pure, isolated, at least mild AS prospectively enrolled at two institutions. The population was divided into four groups: asymptomatic nonsevere AS (n = 55), asymptomatic severe AS with preserved LV ejection fraction (LVEF; ≥50%) (n = 37), symptomatic severe AS with preserved LVEF (n = 60), and severe AS with reduced LVEF (50%) (n = 19).GLS was significantly different among the four groups (P.0001), but the difference was due mainly to patients with reduced LVEFs. In addition, there was an important overlap among the groups, and in multivariate analysis, after adjustment for age, gender, AS severity, and LVEF, GLS was not an independent predictor of symptomatic status (P = .07). BLS was also significantly different among the four groups (P.0001) but in contrast was independently associated with symptomatic status (P.0001). However, as for GLS, there was an important overlap between groups and differences were close to intraobserver or interobserver variability (1.3 ± 1.1% and 2.0 ± 1.6%, respectively).In this prospective multicenter cohort of patients with wide ranges of AS severity, symptoms, and LVEFs, BLS but not GLS was independently associated with symptomatic status. However, there was an important overlap among groups, and differences were close to measurements' reproducibility, raising caution regarding the use of longitudinal strain, at least as a single criterion, in the decision-making process for patients with severe asymptomatic AS.

Aims To evaluate the impact of acoustic window on the feasibility and accuracy of longitudinal global strain (global- ɛ ) by speckle tracking for assessing left ventricular (LV) systolic function. Methods and results The study included 70 patients (57 ± 17 years, 64% men), 28 selected patients with a suboptimal image quality (IQ) defined by three or more segments (4 ± 3 segments/patient) with wall motion score not analysable visually and 42 patients with an optimal two-dimensional (2D) echocardiography IQ. Left ventricular ejection fraction (LVEF) by Simpson's biplane method (2D-EF), global- ɛ by speckle tracking, and peak systolic mitral annulus velocity [systolic tissue Doppler imaging (S-TDI)] were compared with LVEF by cardiac magnetic resonance (EF-CMR; 45 ± 18%, range 9–76%). Speckle-tracking analysis was feasible in all segments with an optimal acoustic window and in 85% (103/121) of segments poorly visualized. Global- ɛ similarly correlated with LVEF by CMR in patients with and without optimal IQ ( r = 0.81 vs. 0.82 for good vs. poor IQ). In contrast, 2D-EF ( r = 0.76) and S-TDI ( r = 0.64) less correlated with LVEF by CMR in patients with a suboptimal IQ. Importantly, IQ only impacted on 2D-EF inter-observer reproducibility (9 ± 5 vs. 24 ± 22% for good vs. poor IQ) but not on global- ɛ reproducibility (9 ± 1 vs. 8 ± 7% for good vs. poor IQ). Conclusion In patients with a limited acoustic window, longitudinal strain by speckle tracking remains accurate and reproducible for assessing global and regional LV systolic function.

Background— Longitudinal myocardial deformation indexes appear superior to left ventricular ejection fraction (LVEF) in assessing myocardial contractility. However, few studies have addressed the prognostic value of longitudinal motion markers (velocity, strain, and strain rate) in predicting outcome in heart failure patients. Methods and Results— The study included 125 consecutive symptomatic heart failure patients (63�16 years, 77% male, LVEF=31�10%). All patients underwent a complete echocardiographic and clinical examination, and brain natriuretic peptide level was assessed in 93 patients. Longitudinal myocardial velocity by tissue Doppler imaging, global-ε, and strain rate by speckle tracking were computed from apical views (4-, 3-, and 2-chambers views) and compared with the occurrence of major adverse cardiac events. On the whole, peak longitudinal velocity, global-ε, and strain rate averaged 5�2 cm/s (range, 1 to 9), −8�3% (range, −3 to −18), and −0.33�0.16 s −1 (range, −0.83 to −0.05), respectively. During the follow-up period (266�177 days), major adverse cardiac events occurred in 47 (38%) patients (15 deaths, 29 recurrent heart failure, and 4 heart transplantations). By univariable analysis using Cox model global-ε, strain rate, and LVEF were associated with the occurrence of major adverse cardiac events, whereas only global-ε remained independently predictive of outcome by multivariate analysis. Conclusions— In the heart failure population, longitudinal global strain by speckle tracking is superior to LVEF and other longitudinal markers in identifying patients with poor outcome.

PurposePost systolic shortening (PSS) and stretching motion occur early during ischemia. Delayed contraction in PSS and stretching motion does not fully contribute to left ventricular end systolic (ES) function and contribute to the left ventricular dysfunction. The wasted energy can be quantified as the difference between peak strain and end systolic strain and used to identify ischemic segments.MethodsAcute myocardial ischemia was induced in 9 anesthetized pigs by balloon coronary occlusion (left coronary descending artery, n=6). Circumferential strain by speckle tracking was computed from short axis view during ischemia at 5’, 30’and 60’. PSS was defined as peak strain occurring after ES and stretching motion as positive systolic peak strain.ResultsBefore induced ischemia, PSS was observed in 38% segments and stretching motion was low (0±1%), then the wasted energy was limited (1±0%). During acute (5’) and prolonged (60’) coronary occlusion, stretching motion increased (4±2% at 5’, and 8±2% at 60’) and PSS became more prevalent (54% and 54%, respectively) and delayed in ischemic segment (3% and 12% of RR interval, respectively). This result the wasted energy was greater in ischemic than non ischemic segment (5±1% vs. 1±1% at 5’, p

ObjectiveTo assess the predictive value of peak global longitudinal strain (e) and e rate by speckle tracking to predict outcome in heart failure (HF) patients.MethodsThe study included 112 consecutive patients admitted for HF (64±13 years, 81% male, 52% ischemia) with reduced left ventricular ejection fraction (LVEF

BackgroundPost-systolic shortening (PSS) is considered as a marker of viability in ischemic left ventricular dysfunction. However, experimental data suggest that PSS can be observed in viable and non viable segments. The aim of the present study was to differentiate PSS segments with and without contractile reserve (CR) using longitudinal strain derived from speckle tracking analysis.MethodsTwenty seven patients (22 males, 5 females; mean age 59±13 yrs.) with ischemic LV dysfunction (mean LVEF 44±12%) underwent low-dose dobutamine echocardiography for viability assessment. Longitudinal strain (ɛ) and strain rate (SR) were assessed at rest and under dobutamine in the 16 segments using speckle tracking analysis. PSS was defined as peak strain occurring after the end-systole. We sought to determine: 1) PSS prevalence according to CR 2) the best indice to predict CR in PSS segments.ResultsOf the 415/432 analysable segments, 148 (38%) exhibited normal and 267 (62%) abnormal contractility at rest (147 hypokinetic, 120 akinetic). PSS was more prevalent in segments without CR than with CR [61% (50/82) vs. 45% (84/185), p=0.002]. Importantly, only peak systolic SR under dobutamine differed between PSS with and without CR (-0.54 ±0.02 s-1 vs. -0.37±0.02 s-1, p

Purpose In some patients, extensive myocardial dysfunction may be observed during acute coronary syndromes despite limited coronary lesions. Mechanism of depressed contractility during ischemia in remote segments is unclear. In the present study, we addressed the changes in myocardial deformation in remote segments during acute experimental ischemia. Methods Acute myocardial ischemia was induced in 9 anesthetized pigs by balloon coronary occlusion (left coronary descending artery, n=6). Radial and circumferential strain by speckle tracking were computed in the 6 mid short axis segment using 2D echocardiography data acquired at 5’, 15’, 30’and 60’of induced ischemia. Results Reduced in peak circumferential (−16%±2 vs. –6±2% p=0.04) and radial (45±5% vs. 17±6 p=0.002) strain occurred early after 5’of coronary occlusion and persisted during ischemia. Interestingly, reduced in peak radial strain (45±4% vs. 22±5% p=0.0005) was also observed in control segments (Figure) during the first stage of ischemia (5’). Compared to ischemic segments, impaired contraction in control segments was brief and recovered after 15’ of ischemia. Importantly only radial but not circumferential strain was affected in control segments. Conclusions A brief reduction in radial motion was observed during acute myocardial ischemia in control segments. This may explain the occurrence of transient and extensive myocardial dysfunction during acute coronary syndromes despite limited lesions. Download : Download full-size image

A 46-year-old man who was diagnosed with familial hypertrophic cardiomyopathy (HCM) related to a heterozygote MYBPC3 (cardiac myosin-binding protein-C) gene mutation at the age of 18 was admitted with cardiogenic shock. A progressive decline in functional capacity started 2 years earlier while successive cardiac magnetic resonance (CMR) imaging performed in 2006, 2010, and 2012 showed focal and progressive myocardial fibrosis ( Panel 1 A ). At admission, bedside echocardiography showed severe HCM and biventricular dysfunction. Femoro-femoral extracorporeal life support …

AimTo assess the value of velocity and flow rate-related parameters obtained by cardiac magnetic resonance (CMR) for evaluation of left ventricular (LV) diastolic function (DF) in patients (pts) with hypertrophic cardiomyopathy (HCM).MethodsCMR was performed in 26 HCM pts and 24 healthy volunteers (HV) matched for age, gender, body surface area (BSA) and blood pressure. DF parameters were obtained using a semi-automated software enabling extraction of transmitral flow, including transmitral Ef and Af flow rate peaks, isovolumetric relaxation time (IVRT) and early peak diastolic longitudinal myocardial velocity E’ obtained using 2D phase contrast-CMR. LV mass and volumes and left atrial (LA) volumes were measured from cine CMR images.ResultsMean age was 47.0±20.2 years in HCM pts and 47.5±16.1 in HV (p=NS). LV mass, mass/end-diastolic volume and LA volumes were increased in HCM pts (table). Late gadolinium enhancement was found in 20 HCM pts. While there was no significant difference in Ef/Af, myocardial longitudinal velocity E’ and LA emptying fraction were markedly lower in HCM pts. Furthermore, E/E’ ratio and E wave deceleration time (DT) were higher in HCM pts. There was a linear relationship between increased LV mass and increased LA volumes (p

Background Intra-ventricular pressure gradient along the direction of the outflow tract is generated by the impulse response of the myocardial contraction. This spatial pressure gradient, derived from the maximal acceleration estimates within the left ventricular (LV) ejection flow, has been validated in vitro by using MRI and was found strongly related to the inotropic state of the LV as demonstrated in animal and human echocardiographic studies. This acceleration may be less dependant on load conditions than others LV systolic function parameters, especially LV ejection fraction (LVEF). Aim: (1) to evaluate the feasibility of LV ejection flow acceleration (Acc) estimates by spatial and temporal derivative of velocities recorded by CMR using phase contrast sequence, (2) to compare the acceleration values to LVEF in patients with Dilated Cardiomyopathy (LVEF

ObjectiveTo compare single and multi beat 3D echocardiography for the assessment of left ventricular (LV) volumes and function.MethodsLV end-diastolic (LVEDV), end-systolic (LVESV) volumes and ejection fraction (LVEF) computed from one and multi-beat (2, 3 and 4) 3D echocardiography (GE-E9, 4DLVQ) were compared to cine-MRI measurements in 50 consecutive patients.ResultsAmong patients with analyzable 3D echocardiography (n=35; LVEDV=155±54mL, LVESV=84±49mL, LVEF=49±14%), single and multi-beat modality provided a fair correlation with MRI for LVED (r2 ranged from 0.8 to 0.85) with no difference for the 95%CI agreement (2SD ranged from 42-50ml). However, agreement for LVES volume was broader for one beat [2SD=41ml] than for multi-beat [2SD=31ml for 2, 35ml for 3 and 4 beat]. Consequently, the best accuracy for LVEF measurement was obtained using two beat modality (r2=0.85; p

ObjectiveTo evaluate the impact of echocardiography 2D image quality on longitudinal global strain for assessing left ventricular (LV) systolic function.MethodsThe study was conducted in 54 patients, 29 with a poor acoustic window (mean=5 non analyzable segments/patient) and 25 with a good 2D image quality. LV ejection fraction (LVEF) by Simpson biplane and longitudinal global strain by speckle tracking were compared to LVEF by MRI.ResultsGlobal strain was closely correlated to LVEF by MRI both in patients with (r=0.79, p