Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography.

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Unveiling the Hidden Patterns: Multimodality Cardiac Imaging in Takotsubo Cardiomyopathy Diagnosis.

Takotsubo cardiomyopathy, also known as stress cardiomyopathy, is a reversible form of cardiomyopathy characterized by reduced ejection fraction with regional wall motion abnormalities, elevated cardiac enzyme levels, and signs of ischemia on electrocardiogram despite the absence of obstructive epicardial coronary artery disease. It is often preceded by intense emotional or physical illness stressors. This case describes a 65-year-old female patient who likely developed takotsubo cardiomyopathy precipitated by the stress of diverticulitis.

Think Outside the Heart: An Unusual Cause of Large Hemopericardium.

Pericardial effusions secondary to tumors are commonly metastatic, originating primarily from the lung, breast, and lymphomas. Pericardial tamponade is a rare oncological emergency warranting early identification and treatment. We describe a 66-year-old male found to have a large bloody pericardial effusion causing tamponade physiology, and multimodality imaging was consistent with intrapericardial malignancy with no identifiable primary source. He was subsequently diagnosed with type B3 thymoma after mediastinal resection.

Relation of Left Ventricular Diastolic Function to Global Fibrosis Burden: Implications for Heart Failure Risk Stratification.

BACKGROUND: Left ventricular (LV) diastolic function is primarily assessed by means of echocardiography, which has limited utility in detecting fibrosis. Cardiac magnetic resonance (CMR) readily detects and quantifies fibrosis. OBJECTIVES: In this study, the authors sought to determine the association of LV diastolic function by echocardiography with CMR-determined global fibrosis burden and the incremental value of fibrosis with diastolic function grade in prediction of total mortality and heart failure hospitalizations. METHODS: A total of 549 patients underwent comprehensive echocardiography and CMR within 30 days. Echocardiography was used to assess LV diastolic function, and CMR was used to determine LV volumes, mass, ejection fraction, replacement fibrosis, and percentage extracellular volume fraction (ECV). RESULTS: Normal diastolic function was present in 142 patients; the rest had diastolic dysfunction grades I to III, except for 18 (3.3%) with indeterminate results. The event rate was higher in patients with diastolic dysfunction compared with patients with normal diastolic function (33.4% vs 15.5; P < 0.001). The model including LV diastolic function grades II and III predicted composite outcome (C-statistic: 0.71; 95% CI: 0.67-0.76), which increased by adding global fibrosis burden (C-statistic: 0.74, 95% CI: 0.70-0.78; P = 0.02). For heart failure hospitalizations, the competing risk model with LV diastolic function grades II and III was good (C-statistic: 0.78; 95% CI: 0.74-0.83) and increased significantly with the addition of global fibrosis burden (C-statistic: 0.80; 95% CI: 0.76-0.85; P = 0.03). CONCLUSIONS: Higher grades of diastolic dysfunction are seen in patients with replacement fibrosis and increased ECV. Fibrosis burden as determined with the use of CMR provides incremental prognostic information to echocardiographic evaluation of LV diastolic function.

Ventricular Septal Rupture Complicating Silent Myocardial Infarction.

A 55-year-old gentleman presented to the emergency department with shortness of breath for the past 3 days. Cardiac magnetic resonance imaging assessed intracardiac shunting and a mechanism of ventricular septal rupture (VSR), showing significant left-to-right shunting and Qp:Qs of 4:1. There was transmural myocardial infarction as well as an aneurysm at the diaphragmatic inferior wall of the left ventricle.

Atypical Presentation of Right Ventricular Cardiac Hamartoma in a Young Man.

Cardiac tumors in adults are exceedingly rare and usually benign. We describe a 29-year-old man with a previous diagnosis of interventricular septal hypertrophy who presented with increasing severity of dyspnea and fatigue. Work-up revealed a 4.9 × 3.7 cm mass at the base of the interventricular septum. Biopsy revealed a benign cardiac hamartoma atypically located in the right ventricle, and the mass was resected via right ventriculotomy.

Atypical Presentation of Marantic Endocarditis.

We describe a 39-year-old man referred for surgical aortic valve replacement for severe symptomatic aortic stenosis. Intraoperative inspection was unexpectedly consistent with marantic endocarditis. Pathology confirmed nonbacterial thrombotic endocarditis. We present high-resolution intraoperative, diagnostic, and pathology images of nonbacterial thrombotic endocarditis in a patient with antiphospholipid syndrome with atypical presentation.

Cardiovascular risk profile of Middle Eastern immigrants living in the United States-the National Health Interview Survey.

BACKGROUND: Middle Eastern (ME) immigrants are one of the fastest-growing groups in the US. Although ME countries have a high burden of atherosclerotic cardiovascular disease (ASCVD), the cardiovascular health status among ME immigrants in the US has not been studied in detail. This study aims to characterize the cardiovascular health status (CVD risk factors and ASCVD burden) among ME immigrants in the US. METHODS: We used 2012-2018 data from the National Health Interview Survey, a US nationally representative survey. ME origin, CVD risk factors, and ASCVD status were self-reported. We compared these to US-born non-Hispanic white (NHW) individuals in the US. RESULTS: Among 139,778 adults included, 886 (representing 1.3 million individuals, mean age 46.8) were of ME origin, and 138,892 were US-born NHWs (representing 150 million US adults, mean age 49.3). ME participants were more likely to have higher education, lower income and be uninsured. The age-adjusted prevalence of hypertension (22.4% vs 27.4%) and obesity (21.4% vs 31.4%) were significantly lower in ME vs NHW participants, respectively. There were no significant differences between the groups in the age-adjusted prevalence of ASCVD, diabetes, hyperlipidemia, and smoking. Only insufficient physical activity was higher among ME individuals. ME immigrants living in the US for 10 years or more reported higher age-adjusted prevalence of hypertension, hyperlipidemia, and ASCVD. CONCLUSIONS: ME immigrants in the US have lower odds of hypertension and obesity, and of having a suboptimal CRF profile compared to US-born NHWs. Further studies are needed to determine whether these findings are related to lower risk, selection of a healthier ME subgroup in NHIS, or possible under-detection of cardiovascular risk factors in ME immigrants living in the US.

Outcomes of patients with moderate-to-severe Ischemia excluded from the ischemia trial.

BACKGROUND: The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial showed no difference in outcomes between medical therapy vs coronary revascularization in the management of patients with stable coronary artery disease. We aimed to determine the percentage of patients with at least moderate ischemia that would have been eligible for enrollment and evaluate the outcomes of those who would not. METHODS: Consecutive patients who underwent cardiac single-photon emission computed tomography (SPECT) between April 2016 and September 2019 were identified and all-cause mortality was determined. RESULTS: There were a total of 1508 patients (mean age 67 ± 11.6 years, 69.5% males) with any perfusion defect on SPECT. Patients had a high prevalence of cardiac risk factors (73.4% with hypertension and 54.4% with diabetes mellitus.) Nearly half (709, 47%) had moderate-to-severe ischemia but over two-thirds (479/709, 66.3%) had at least one ISCHEMIA trial exclusion criteria. Patients meeting ISCHEMIA enrollment criteria had a significantly lower all-cause mortality than those who would have been excluded (3.91% vs. 11.3%, respectively, P < .001). CONCLUSION: Our results show that ISCHEMIA selected a relatively small subset of lower risk patients among the larger higher risk group of patients with moderate-to-severe ischemia typical to most cardiology centers.

Cardiac involvement in hospitalized patients with COVID-19 and its incremental value in outcomes prediction.

Recent reports linked acute COVID-19 infection in hospitalized patients to cardiac abnormalities. Studies have not evaluated presence of abnormal cardiac structure and function before scanning in setting of COVD-19 infection. We sought to examine cardiac abnormalities in consecutive group of patients with acute COVID-19 infection according to the presence or absence of cardiac disease based on review of health records and cardiovascular imaging studies. We looked at independent contribution of imaging findings to clinical outcomes. After excluding patients with previous left ventricular (LV) systolic dysfunction (global and/or segmental), 724 patients were included. Machine learning identified predictors of in-hospital mortality and in-hospital mortality + ECMO. In patients without previous cardiovascular disease, LV EF < 50% occurred in 3.4%, abnormal LV global longitudinal strain (< 16%) in 24%, and diastolic dysfunction in 20%. Right ventricular systolic dysfunction (RV free wall strain < 20%) was noted in 18%. Moderate and large pericardial effusion were uncommon with an incidence of 0.4% for each category. Forty patients received ECMO support, and 79 died (10.9%). A stepwise increase in AUC was observed with addition of vital signs and laboratory measurements to baseline clinical characteristics, and a further significant increase (AUC 0.91) was observed when echocardiographic measurements were added. The performance of an optimized prediction model was similar to the model including baseline characteristics + vital signs and laboratory results + echocardiographic measurements.

Added prognostic value of plaque burden to computed tomography angiography and myocardial perfusion imaging.

BACKGROUND AND AIMS: Cardiac computed tomographic angiography (CCTA) - derived measures of coronary artery disease (CAD) burden have been shown to independently predict incident cardiovascular events. We aimed to compare the added prognostic value of plaque burden to CCTA anatomic assessment and single photon emission computed tomography (SPECT) physiologic assessment in a cohort with high prevalence of risk factors undergoing both tests. METHODS: Consecutive patients who underwent clinically indicated CCTA and SPECT myocardial imaging for suspected CAD were included. Stenosis severity and segment involvement score (SIS - number of segments with plaque irrespective of stenosis) were determined from CCTA, and presence of ischemia was determined from SPECT. Patients were followed for major adverse cardiovascular events (MACE, inclusive of all-cause death, non-fatal myocardial infarction, and percutaneous coronary intervention or coronary artery bypass grafting 90-days after imaging test.) RESULTS: A total of 956 patients were included (mean age 61.1 ± 14.2 years, 54% men, 89% hypertension, 81% diabetes, 84% dyslipidemia). Obstructive stenosis (left main ≥50%, all other coronary segments ≥70%) and ischemia were observed in a similar number of patients (14%). In multivariable Cox regression models, SIS significantly predicted outcomes and improved risk discrimination in models with CCTA obstructive stenosis (HR 1.15, p ≤ 0.001; Harrel's C 0.74, p = 0.008) and SPECT ischemia (HR 1.14, p < 0.001; Harrel's C 0.76, p = 0.019). CONCLUSIONS: Our results suggest that in patients with suspected CAD and a high prevalence of risk-factors, plaque burden adds incremental prognostic value over established CCTA and SPECT measures to predict incident cardiovascular outcomes.

Mitral Valve Remodeling and Strain in Secondary Mitral Regurgitation: Comparison With Primary Regurgitation and Normal Valves.

OBJECTIVES: The aim of this study was to assess mitral valve (MV) remodeling and strain in patients with secondary mitral regurgitation (SMR) compared with primary MR (PMR) and normal valves. BACKGROUND: A paucity of data exists on MV strain during the cardiac cycle in humans. Real-time 3-dimensional (3D) echocardiography allows for dynamic MV imaging, enabling computerized modeling of MV function in normal and disease states. METHODS: Three-dimensional transesophageal echocardiography (TEE) was performed in a total of 106 subjects: 36 with SMR, 38 with PMR, and 32 with normal valves; MR severity was at least moderate in both MR groups. Valve geometric parameters were quantitated and patient-specific 3D MV models generated in systole using a dedicated software. Global and regional peak systolic MV strain was computed using a proprietary software. RESULTS: MV annular area was larger in both the SMR and PMR groups (12.7 ± 0.7 and 13.3 ± 0.7 cm2, respectively) compared with normal subjects (9.9 ± 0.3 cm2; p < 0.05). The leaflets also had significant remodeling, with total MV leaflet area larger in both SMR (16.2 ± 0.9 cm2) and PMR (15.6 ± 0.8 cm2) versus normal subjects (11.6 ± 0.4 cm2). Leaflets in SMR were thicker than those in normal subjects but slightly less than those with PMR posteriorly. Posterior leaflet strain was significantly higher than anterior leaflet strain in all 3 groups. Despite MV remodeling, strain in SMR (8.8 ± 0.3%) was overall similar to normal subjects (8.5 ± 0.2%), and both were lower than in PMR (12 ± 0.4%; p < 0.0001). Valve thickness, severity of MR, and primary etiology of MR were correlates of strain, with leaflet thickness being the multivariable parameter significantly associated with MV strain. In patients with less severe MR, anterior leaflet strain in SMR was lower than normal, whereas strain in PMR remained higher than normal. CONCLUSIONS: The MV in secondary MR remodels significantly and similarly to PMR with a resultant larger annular area, leaflet surface area, and leaflet thickness compared with that of normal subjects. Despite these changes, MV strain remains close to or in some instances lower than normal and is significantly lower than that of PMR. Strain determination has the potential to improve characterization of MV mechano-biologic properties in humans and to evaluate its prognostic impact in patients with MR, with or without valve interventions.

Valve Strain Quantitation in Normal Mitral Valves and Mitral Prolapse With Variable Degrees of Regurgitation.

OBJECTIVES: The aim of this study was to quantitate patient-specific mitral valve (MV) strain in normal valves and in patients with mitral valve prolapse with and without significant mitral regurgitation (MR) and assess the determinants of MV strain. BACKGROUND: Few data exist on MV deformation during systole in humans. Three-dimensional echocardiography allows for dynamic MV imaging, enabling digital modeling of MV function in health and disease. METHODS: Three-dimensional transesophageal echocardiography was performed in 82 patients, 32 with normal MV and 50 with mitral valve prolapse (MVP): 12 with mild mitral regurgitation or less (MVP - MR) and 38 with moderate MR or greater (MVP + MR). Three-dimensional MV models were generated, and the peak systolic strain of MV leaflets was computed on proprietary software. RESULTS: Left ventricular ejection fraction was normal in all groups. MV annular dimensions were largest in MVP + MR (annular area: 13.8 ± 0.7 cm2) and comparable in MVP - MR (10.6 ± 1 cm2) and normal valves (10.5 ± 0.3 cm2; analysis of variance: p < 0.001). Similarly, MV leaflet areas were largest in MVP + MR, particularly the posterior leaflet (8.7 ± 0.5 cm2); intermediate in MVP - MR (6.5 ± 0.7 cm2); and smallest in normal valves (5.5 ± 0.2 cm2; p < 0.0001). Strain was overall highest in MVP + MR and lowest in normal valves. Patients with MVP - MR had intermediate strain values that were higher than normal valves in the posterior leaflet (p = 0.001). On multivariable analysis, after adjustment for clinical and MV geometric parameters, leaflet thickness was the only parameter that was retained as being significantly correlated with mean MV strain (r = 0.34; p = 0.008). CONCLUSIONS: MVs that exhibit prolapse have higher strain compared to normal valves, particularly in the posterior leaflet. Although higher strain is observed with worsening MR and larger valves and annuli, mitral valve leaflet thickness-and, thus, underlying MV pathology-is the most significant independent determinant of valve deformation. Future studies are needed to assess the impact of MV strain determination on clinical outcome.

Association Between FFRCT and Instantaneous Wave-Free Ratio (iFR) of Intermediate Lesions on Coronary Computed Tomography Angiography.

BACKGROUND: New data suggests long term outcomes of coronary revascularization based on instantaneous wave free ratio (iFR) are equivalent to invasive fractional flow reserve (FFR). We aimed to evaluate the correlation between non-invasive FFR derived from cardiac CT (FFRCT) and iFR. METHODS: Data from 21 patients with 26 vessels, who underwent both FFRCT computation and invasive iFR measurement, were analysed. We evaluated diagnostic performance of FFRCT according to two cut-off values of ≤0.80 and ≤0.70 with iFR ≤0.89 as the reference standard. RESULTS: In a per vessel analysis, the average diameter stenosis was 59%, mean FFRCT was 0.81 while mean iFR was 0.90. Using an FFRCT cut-off of 0.80, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for FFRCT were 86%, 84%, 67%, 94%, and 85% respectively. When the cut-off was lowered to 0.70, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for FFRCT were 57%, 100%, 100%, 86% and 88% respectively. CONCLUSION: FFRCT correlates well with iFR in this small retrospective study. Larger studies are required to confirm this finding.

Imaging in mitral stenosis.

PURPOSE OF REVIEW: Mitral stenosis remains clinically relevant in developing countries where rheumatic heart disease is the predominant culprit. In the western world, mitral annular and valvular calcification is an increasingly recognized cause, particularly in an aging population. Echocardiography plays a primary role in imaging mitral stenosis with a growing role for cardiac computed tomography and magnetic resonance imaging. In this review, we aim to revisit mitral stenosis assessment and quantification using multimodality imaging. RECENT FINDINGS: There is an increasing role for advanced cardiac imaging especially in the era of transcatheter mitral valve intervention. Also, when echocardiography is suboptimal or discordant with symptoms, computed tomography can provide anatomical data, whereas magnetic resonance imaging can provide anatomical along with hemodynamic data. SUMMARY: Diagnosis of mitral stenosis is crucial as it carries an increased morbidity and mortality risk. Echocardiography is the cornerstone imaging modality with alternative, complementary advanced imaging considered when images are suboptimal.

CMR in the Evaluation of Diastolic Dysfunction and Phenotyping of HFpEF: Current Role and Future Perspectives.

Heart failure with preserved ejection fraction presents a challenging diagnosis given a heterogeneous patient population and limited therapeutic options. Diastolic function assessment using echocardiography has been a cornerstone in the work-up and is as important as systolic functional assessment. There has been increased awareness to the potential utility of cardiac magnetic resonance (CMR) imaging over the past decade as a promising, radiation-free, robust imaging modality providing an unrestricted field of view and high-resolution images for global and regional functional assessment. CMR provides early markers for detecting myocardial disease using tissue characterization imaging, which might prove useful to improve diagnosis and management. Over the years, several studies have examined CMR-derived diastolic functional indices, including transmitral and pulmonary venous velocities, left ventricular and left atrial strain using myocardial tagging, and, more recently, feature tracking. The relevance of imaging-based diastolic function indices and their clinical application across different modalities is increasingly recognized.

Assessment of myocardial viability by PET.

PURPOSE OF REVIEW: Viability assessment has a key role in the management of patients with ischemic heart disease. Positron emission tomography (PET) is a unique modality that evaluates myocardial viability via assessing the tissues metabolic and perfusion properties. The mainstay of metabolic imaging relies on glucose metabolism using fluorodeoxyglucose, a radiolabeled glucose analog. Mismatch in perfusion metabolism data denotes hibernating myocardium with a high likelihood of functional recovery following revascularization. Matched absence or reduction in perfusion metabolism data represents scar with a low likelihood of functional recovery following revascularization. This review will focus on PET radiotracers and techniques used to assess myocardial viability. RECENT FINDINGS: Single-center studies have shown that patients with PET mismatch undergoing bypass grafting had improved survival compared with those on medical therapy. In addition to survival benefit, the patients who underwent PET-guided revascularization had significant improvement in angina and heart failure symptomology. Recent technological advancements in the field of PET-magnetic resonance (MR) opens a new frontier in the field of advanced imaging as it combines anatomical, functional, tissue characterization, and metabolic perfusion data obtained in one setting. The incremental value of PET/MRI is best established in diagnosing and monitoring disease activity in patients with cardiac sarcoidosis and occult malignancies, but more studies are needed to assess it value in viability assessment. SUMMARY: In conclusion, imaging myocardial viability by PET provides assessment of both physiological perfusion and myocardial tissue's metabolic activity to differentiate hibernating from scarred myocardium.

Advanced Cardiac Imaging for Complex Adult Congenital Heart Diseases.

The population of patients with adult congenital heart disease has grown and is currently estimated to include approximately 1 million people in the United States. Cardiologists and imagers frequently encounter complex patients who have undergone multiple prior operations and interventions. A myriad of imaging tests are currently available, including echocardiography, cardiovascular magnetic resonance imaging, and computed tomography, all of which collectively provide invaluable information on cardiac anatomy and hemodynamics. Advanced imaging plays a role in diagnosis and preprocedural planning and also determines the need and frequency of follow-up. This article provides a contemporary review of the current role of cardiac imaging in patients with complex congenital heart disease.