Detection of disease progression is key to personalize treatment strategies in transthyretin cardiomyopathy (ATTR-CM), particularly with emerging therapies. Echocardiography can detect subtle longitudinal changes but is limited by operator dependence. This study evaluates agreement and reproducibility of fully automated, AI-assisted echocardiographic measurements under real-world conditions. This retrospective study included 62 patients with ATTR-CM undergoing 178 serial annual echocardiograms assessed by a reference human reader, a second cardiologist (cardiologist 2), a novice reader, and a fully automated AI algorithm (Us2.ai). Interrater agreement was assessed using Bland-Altman analysis and intraclass correlation coefficients (ICCs). Intrarater variability for human readers was derived from repeated blinded measurements, with limits of agreement (LoA = mean difference ± 1.96 × SD) defining the minimal detectable change. AI repeatability was assessed using within-study automated pipeline variability across available acquisitions. AI showed moderate agreement with the reference human reader for IVSd and LVEDV (ICC 0.65 and 0.51), with biases of - 1.9 mm and - 39 mL, respectively. Interrater agreement between cardiologists was good (ICC 0.79 and 0.84) with minimal bias (- 0.2 mm and + 3 mL). Intrarater variability was moderate to excellent for both cardiologists (LoA 3.0 mm and 43 mL for the reference human reader; 2.7 mm and 44 mL for cardiologist 2). AI demonstrated comparable repeatability (LoA 3.6 mm and 37 mL), while the novice showed higher variability (5.1 mm and 61 mL). Fully automated measurements showed within-study variability of similar magnitude to the intrarater variability of experienced readers, although obtained with different experimental designs, supporting further prospective evaluation for serial assessment. Agreement in absolute terms was moderate for wall thickness and LV volumes, indicating expert oversight remains necessary in advanced disease.

Left atrial (LA) volume is a powerful prognostic factor in cardiovascular disease with emerging AI-driven quantification from non-contrast coronary artery calcium (CAC) CT. The accuracy and agreement of such volume quantification with echocardiography, however, is not well studied. This study compares LA volumes captured from CAC CT and transthoracic two-dimensional echocardiography (2DE). This retrospective cohort included 220 patients undergoing both echocardiography and CAC CT within a 1-year period. CAC CT images were analyzed using a deep learning-based autoencoder model to derive chamber volumes. LA volume measurements were compared using Pearson correlation and Bland-Altman plots. Sub analysis was performed based on CT cardiac phase, body mass index, and sex with LA volume indexed to body-surface area (BSA). Mean LA volume differed significantly between 2DE and CAC CT with volumes of 32.2 ± 13.7 mL/m2 and 45.7 ± 15.9 mL/m2 (P < 0.001), respectively. CAC CT-derived LA volume correlated strongly with 2DE-measured LA volume (r = 0.82, ICC = 0.57, P < 0.001) and substantially with clinical severity (Cohen's κ = 0.70, P < 0.001). 2D-echo systematically underestimated LA volume with CAC-CT, with bias of 13.5 mL/m2 [95% CI, 12.3-14.7]. Agreement remained consistent for patients with (r = 0.83, ICC = 0.66, P < 0.001) and without (r = 0.77, ICC = 0.62, P < 0.001) heart failure. Inter-modality agreement for chamber volumes remained robust across sex, BMI, cardiac phase, and vendor sub-analyses. AI-derived LA volume from CAC CT demonstrated strong correlations with 2DE measurements and severity regardless of cardiac phase, BMI, and sex. Despite systematic differences in absolute volume compared to 2DE, CAC CT revealed relative LA remodeling, supporting the use of CAC CT as a modality for chamber quantification.

Peripartum cardiomyopathy (PPCM) is a rare but potentially life-threatening cause of heart failure that requires prompt recognition and exclusion of alternative etiologies. This case highlights the complementary roles of computed tomography and cardiac magnetic resonance (CMR) in the peripartum patient with acute heart failure.

Angiography-derived indices of microvascular resistance offer wire-free assessment from routine angiograms, but their validity in hypertrophic cardiomyopathy (HCM) remains uncertain. We evaluated correlation, agreement, diagnostic performance, and reproducibility of angiography-derived IMR versus invasive pressure-wire IMR in HCM. Consecutive HCM patients without obstructive coronary artery disease underwent invasive left anterior descending artery IMR during adenosine hyperaemia. Angiography-derived IMR was computed offline using three-dimensional reconstruction, QFR, TIMI frame count, and pressure assumptions. Analyses included Spearman correlation, Bland-Altman agreement, ROC analysis, and intraclass correlation coefficients. Thirty patients were included. Invasive IMR was ≥ 25 mmHg × s in 20 patients (67%). Angiography-derived IMR correlated moderately with invasive IMR (Spearman r = 0.53, 95% CI 0.21-0.75; P = 0.003). Bland-Altman analysis showed a mean bias of 4.1 mmHg × s, with 95% limits of agreement from - 28.4 to 36.6 mmHg × s. Angiography-derived IMR identified invasive IMR ≥ 25 mmHg × s with an AUC of 0.83 (95% CI 0.65-0.96). The optimal cutoff was 26, yielding 80% sensitivity (95% CI 56-94%) and 80% specificity (95% CI 44-97%). Intra-observer reproducibility was high and inter-observer reproducibility moderate. In HCM, angiography-derived IMR showed moderate correlation and acceptable cohort-level discrimination but wide agreement limits, indicating limited individual-level interchangeability. HCM-specific refinement is required before replacing invasive microvascular assessment.Clinical trial registration: ClinicalTrials.gov identifier: NCT03479580.

Hypertrophic cardiomyopathy (HCM) patients have an increased risk of heart failure (HF), arrhythmias and sudden cardiac death (SCD). There are a lack of studies comparing the prognostic value of cardiac magnetic resonance (CMR) determined left ventricular (LV) global longitudinal strain (LVGLS), left atrial strain (LAS), and late gadolinium enhancement (LGE). This retrospective study aims to identify the significant independent predictor(s) of MACE in patients with HCM. HCM patients who underwent CMR examinations between 2008 and 2022 at 5 medical sites were recruited. CMR feature-tracking (FT) was used to determine LV strain (LVS) and LAS. LGE was quantified. Primary outcome was a composite outcome of MACE (i.e., HF hospitalisation, cardiac arrest and all-cause mortality). Univariate and multivariate Cox regression analyses included clinical parameters, HCM features, medications, LVS, LAS and LGE. Kaplan-Meier analyses with log-rank tests were performed. 468 patients (308 males, median age of 64) were included. 147 patients experienced MACE with a median follow-up of 7.6 years. Patients with MACE had smaller LVGLS (- 8.03% vs - 10.05%; p < 0.001), as well as smaller left atrial reservoir strain (LASr) (15.13% vs 23.13%; p < 0.001), left atrial conduit strain (LAScd), and left atrial booster strain (LASb) (8.885 vs 12.57%; p < 0.001). However, LGE quantification showed no significant difference (9.76% vs 8.92%; p < 0.535). On Kaplan-Meier analysis, all LVS and LAS parameters were significantly associated with MACE (p < 0.001), while only LVGLS and LAS parameters were significantly associated with all-cause mortality. On multivariable Cox regression analysis, all three LAS parameters were significant independent predictors of the composite outcome (p <0.05). LVS parameters were no longer significant on multivariable Cox regression. LASr, LAScd and LASb are significant independent predictors of MACE in CMR for assessing prognosis in HCM patients. LGE quantification was not a significant independent predictor.

To assess the association of transaortic flow-rate (TFR) with symptom-driven aortic valve replacement (AVR) in asymptomatic patients with moderate to severe aortic stenosis (AS). PRIMID was a prospective, multi-centre observational study. Patients with asymptomatic moderate to severe AS underwent transthoracic echocardiography (TTE), cardiopulmonary exercise testing and stress cardiovascular magnetic resonance (CMR) imaging. TFR was calculated as stroke volume divided by left ventricular ejection time. Patients were followed-up for a minimum of one-year initially. The primary outcome was symptom-driven AVR. Long-term follow-up data was obtained through electronic health records. The secondary outcome was long-term major adverse cardiovascular events (MACE) defined as cardiovascular mortality and hospitalisation with heart failure, myocardial infarction, syncope or arrhythmia. We included 171 individuals: mean age 66.21±3.43 years, 76% male, mean aortic valve area 1.12±0.31cm2. At one-year (median: 366 days, IQR: 312-437) there were 47 symptom-driven AVRs. Over long-term follow-up of 6.52 years (IQR: 5.23-7.22), there were 95 symptom-driven AVRs and 47 MACE events. In multivariable models, TFR was associated with symptom-driven AVR at one-year (HR: 0.12, 95%CI: 0.04-0.39, p<0.01), independent of a positive exercise tolerance test and CMR-measured myocardial perfusion reserve. Age (HR: 1.05, 95%CI: 1.01-1.10, p=0.01) and NT-pro-BNP (HR: 1.46, 95%CI: 1.12-1.89, p<0.01) predicted long-term MACE events, while TFR did not (HR: 0.48, 95%CI: 0.13, 1.74, p=0.26). TFR is independently associated with symptom-driven AVR in initially asymptomatic individuals with moderate to severe AS at one-year. TFR may be useful in identifying individuals who will undergo symptom-driven intervention, but prospective randomised data are needed to assess clinical utility.

The prognosis of patients with mitral valve prolapse (MVP) largely depends on the presence of ventricular arrhythmias. This study aims to identify association between Cardiac MRI (CMR) based findings with ventricular arrhythmias in MVP patients. Consecutive patients (n = 45, mean age 56 ± 17 y) with MVP underwent CMR scans. Premature ventricular beats (PVC) and ventricular tachycardia (VT) were recorded by 24-hour Holter monitoring and exercise stress testing. Myocardial late gadolinium enhancement (M -LGE) was calculated as percentage of left ventricular (LV) mass and was analyzed by tertiles - 1st tertile (0%), 2nd (1-4%) and 3rd tertile ≥ 5% of the LV mass. Mitral annular disjunction (MAD) was measured in millimeters in a 3-chamber steady state free precession (SSFP) sequence. Papillary muscle fibrosis (PM - LGE) presence was recorded using the LGE sequence. The combined clinical endpoint (CEP) was defined as the presence of VT, multiple (> 10%) or multiform PVC, ablation due to ventricular arrhythmia and implantable cardioverter defibrillator insertion. M-LGE > 0% in 27 patients (64%) was recorded. The CEP was documented in 47%, 46% and 93% of the 1st, 2nd and 3rd M - LGE% tertiles, respectively (p value = 0.014). A multivariable logistic regression analysis assessing associations with CEP, including LV ejection fraction, PM-LGE, and M-LGE%, was performed. M - LGE% remains strongly associated with CEP as a continuous variable, as well as in the 3rd tertile: OR 1.43; 95%CI 1.05-1.94, p = 0.02 and OR 13.41 95%CI 1.49-120.67, p = 0.02, respectively. Myocardial fibrosis detected by CMR - LGE, particularly when ≥ 5% of LV mass was strongly associated with arrhythmic risk in MVP. CMR - based fibrosis quantification should be considered in routine evaluation to improve risk stratification.

Right heart failure (RHF) remains a major determinant of morbidity and mortality following left ventricular assist device (LVAD) implantation. Right ventricular free wall strain (RVFWS) and global longitudinal strain (RVGLS) have emerged as promising echocardiographic markers, yet their long-term prognostic utility and suitability to assess changes in RV function remain poorly defined.In this single-center retrospective study, 57 of 95 consecutive HeartMate 3 LVAD recipients (mean age 57 ± 11 years; 79% male) with adequate echocardiographic quality were analyzed. Patients were stratified by RHF phenotype as no RHF (n = 28) or RHF (n = 29; comprising early acute and early postoperative RHF). RVFWS and RVGLS were measured preoperatively and at 2 weeks, 6 months, 12 months, and 36 months post-implantation using speckle-tracking echocardiography. Predictive value was assessed using logistic regression and ROC analysis; longitudinal change using linear mixed-effects models (LMM); and outcomes using Kaplan-Meier, Cox regression, restricted mean survival time (RMST), and competing-risks analyses.Preoperative RVFWS was lower in patients who developed RHF (-6.0% (IQR-9.5, -4.1) vs. -10.5% (IQR-12.6, -6.8); p = 0.037). Preoperative RVFWS predicted RHF with an AUC of 0.66 (95% CI 0.52-0.81), an optimal cut-off of -6.3%, 55% sensitivity and 79% specificity; no other echocardiographic parameter (RVGLS, TAPSE, RVEDD/LVEDD, FAC) discriminated RHF, and no parameter was an independent predictor on multivariable analysis. On LMM, RVFWS declined early in the no-RHF group (Δ + 3.3 at 2 weeks, p = 0.005; Δ + 3.0 at 6 months, p = 0.022 vs. baseline) and then stabilized; this pattern was robust in complete-case and random-slope sensitivity analyses. RVGLS improved in the RHF group by 12 months (Δ-3.3, p = 0.010). No between-group difference was detected at any single time point. One- and two-year survival was 85% and 80% in the no-RHF group versus 61% and 57% in the RHF group; restricted mean survival time to 2 years was 169 days shorter in the RHF group (p = 0.018), reflecting significantly higher first-year mortality (HR 3.2; p = 0.044) without a later difference. Transplant incidence was similar between groups and competing-risks analysis was concordant.Preoperative RVFWS provides modest discrimination between RHF and non-RHF after LVAD implantation. Serial strain captures dynamic RV changes - an early postoperative decline in RVFWS in patients without RHF and a later recovery of RVGLS in those with RHF - and RHF is associated with worse early survival. Serial RV strain may therefore complement, rather than replace, established risk assessment.

In severe rheumatic mitral stenosis (MS), left ventricular (LV) systolic function is often considered preserved based on ejection fraction. However, longitudinal myocardial mechanics may be impaired and may improve after relief of inflow obstruction. The regional pattern of strain recovery following percutaneous mitral balloon valvuloplasty (PMBV), and its prognostic implications remain uncertain. To characterize global and regional LV strain response following PMBV, identify determinants of limited strain recovery, and evaluate its association with long-term outcomes. In 190 patients with severe symptomatic MS undergoing PMBV, LVGLS was measured by speckle-tracking echocardiography before and within 48 h after intervention. Absence of meaningful recovery was defined as ≤ 15% relative GLS improvement. The secondary endpoint was cardiovascular death or subsequent mitral valve replacement. PMBV significantly increased mitral valve area and reduced transmitral gradients, with concomitant improvement in GLS despite unchanged ejection fraction. Strain recovery demonstrated a distinct basal-to-apical gradient, with the greatest improvement in basal segments. In 29% of patients, absent GLS improvement was observed. Limited recovery was independently associated with larger baseline valve area, reduced leaflet displacement, lower pre-procedural left atrial pressure, and higher post-procedural pulmonary artery pressure. Over 48 months of follow-up, adverse outcomes were independently predicted by age, advanced NYHA class, smaller post-procedural valve area, higher residual gradient, and greater mitral regurgitation severity. Absence of GLS improvement was not associated with long-term events. In severe rheumatic MS, PMBV leads to an immediate improvement in LV longitudinal mechanics, characterized by a distinct basal predominance of recovery. This response appears largely load-mediated and does not independently translate into improved prognosis, which is primarily determined by procedural success and the degree of residual valve obstruction.

Detecting perivalvar infection including aortic root abscesses and pseudoaneurysms in infective endocarditis remains challenging, and standard transoesophageal echocardiography (TEE) often leaves diagnostic uncertainty. This study examines whether adding cardiac computed tomography (CCT) improves detection of such complications. 32 endocarditis cases who underwent TEE, CCT, and cardiac surgery were retrospectively analysed. Three expert cardiologists independently reviewed anonymised TEEs followed by corresponding CCTs. Diagnostic performance for detecting aortic root abscesses and pseudoaneurysms was assessed against surgical findings as gold standard. ROC curves and AUC compared the two modalities. 13/32 cases had abscess/pseudoaneurysms (8 abscesses, 8 pseudoaneurysms). Accuracy increased from 88% with TEE to 91% with TEE + CCT. Sensitivity improved from 85% to 100% while specificity decreased from 89% to 84%. CCT increased NPV to 100% and diagnostic confidence in 91% of cases. AUC tended higher for TEE + CCT than TEE alone (0.92 vs. 0.87, p = 0.47). For pseudoaneurysms, CCT increased AUC (TEE + CCT=0.98 vs. TEE = 0.67, p = 0.001). Adding CCT to TEE improved the detection and exclusion of abscess/pseudoaneurysms, although results should be interpreted cautiously due to the sample size. The combination increased sensitivity at the expense of a small reduction in specificity, achieved a NPV of 100% and increased diagnostic confidence in physicians, supporting CCT as complementary imaging. The greatest benefit was for pseudoaneurysms, where TEE + CCT identified all and significantly improved AUC, whereas the overall improvement was less pronounced when abscesses were included. Given the rarity of these complications and the limited sample size, larger prospective studies are warranted to confirm these findings.

Several equations have been proposed to non-invasively estimate pulmonary artery wedge pressure (PAWP) and have been validated against right heart catheterization (RHC). However, their accuracy in patients with advanced heart failure (AdvHF) remains uncertain. We assessed the agreement between echocardiographic and invasive PAWP measurements at rest and during vasodilator testing. Consecutive patients referred for AdvHF undergoing paired transthoracic echocardiography (TTE) and RHC within 24 hours were prospectively enrolled. Echocardiographic PAWP was calculated with the Nagueh E/e' equation and with the left atrial volume index (LAVi) and mitral E-based equation reported by Lindow (ePAWP-E). Agreement with invasive PAWP was assessed by Spearman correlation and Blant-Altman analysis, and discrimination for elevated PAWP (≥ 15 mmHg) by receiver operating characteristic (ROC) analysis, overall and in the pre-specified subgroup with left atrial volume index (LAVi) < 48 mL/m[2]. In patients undergoing sodium nitroprusside challenge, invasive and echocardiographic PAWP change (ΔPAWP) was analyzed and compared. Of 176 patients enrolled, 172 (mean age was 52.6 ± 12.1 years and 76.2% were males), had an interpretable PAWP and formed the analytic cohort; 77 (44.8%) had PAWP ≥ 15 mmHg. Correlation with invasive PAWP was ρ = 0.452 for Nagueh (n = 148) and ρ = 0.550 for ePAWP-E (n = 156, both p < 0.001), with AUC 0.759 (95% CI 0.677-0.833) and 0.798 (95% CI 0723-0.864). Both equations overestimated invasive PAWP (bias + 3.2 and + 2.6 mmHg) with wide limits of agreement (-13.3 to + 19.7 and - 11.6 to + 16.8 mmHg). In the LAVi < 48 mL/m[2] subgroup, agreement improved (ρ = 0.496 vs. 0.655; AUC 0.850 and 0.927) and the limits of agreement for ePAWP-E narrowed to - 8.3 to + 10.3 mmHg. During nitroprusside challenge, invasive ΔPAWP was 9.6 ± 7.6 mmHg whereas echocardiographic ΔePAWP was 2.4 ± 5.6 mmHg (Nagueh, n = 33) and 1.5 ± 6.0 mmHg (ePAWP-E, n = 34; both p < 0.001 vs. invasive), with weak Δ correlations (ρ = 0.414 and 0.389). In AdvHF, echocardiographic equations correlate only moderately with invasive PAWP and are not accurate enough for individual-level quantification. The LAVi- and E-based equation performs best and may be used to rule in or rule out elevated filling pressures at rest when the left atrium is not severely dilated. Neither equation tracks the acute PAWP changes induced by vasodilator challenge, so RHC remains indispensable whenever the clinical question is dynamic.

Coronary CT angiography (CCTA) is widely used for monitoring patients after stent implantation, but beam-hardening and blooming artifacts make assessment of in-stent restenosis (ISR) challenging. This study developed and evaluated a deep learning algorithm for automated detection of significant ISR in CCTA images. A retrospective analysis of 257 patients with 408 stents was conducted, divided into a development set (n = 126 patients, 186 stents) and an internal validation set (n = 131 patients, 222 stents), with invasive coronary angiography serving as the reference standard. The algorithm's diagnostic performance was compared to two expert radiologists using standard diagnostic metrics. The deep learning algorithm achieved 87.8% accuracy (95% confidence interval [CI], 82.9-91.5%), with sensitivity of 75.4% (95% CI, 62.9-84.8%), specificity of 92.1% (95% CI, 87.0-95.3%), positive predictive value (PPV) of 76.8% (95% CI, 64.2-85.9%), and negative predictive value (NPV) of 91.6% (95% CI, 86.3-94.9%). McNemar's test revealed no significant differences in overall diagnostic accuracy between the algorithm and Reader1 (p = 0.133) or Reader2 (p = 0.150). Notably, the algorithm demonstrated significantly higher sensitivity compared to both readers (43.9% [95% CI, 31.8-56.7%] and 56.1% [955% CI, 43.3-68.2%], p < 0.05) and higher NPV compared to Reader1 (p = 0.026). Subgroup analyses confirmed higher sensitivity across different scanner platforms and imaging conditions, including GE systems (p = 0.016) and 80 kilovoltage peak settings (p = 0.006). The deep learning algorithm demonstrated higher sensitivity for detecting significant ISR while maintaining comparable overall diagnostic accuracy to expert radiologists, although this was accompanied by numerically slightly lower specificity, supporting its potential as a decision-support tool.

In anomalous aortic origin of a coronary artery (AAOCA), coronary CT angiography (CCTA) is the primary tool for anatomical assessment. However, CCTA measurements lack validation against a high-resolution in-vivo standard. To assess CCTA reliability for lumen dimensions and intramural length (IML) in AAOCA, and to validate these against a three-dimensionally reconstructed intravascular ultrasound (3D-IVUS) reference using three additional IML methodologies. A total of 60 AAOCA patients with an interarterial/intramural course underwent both CCTA and IVUS. A 3D-IVUS was constructed and its geometric reproducibility assessed. CCTA reliability and agreement with 3D-IVUS were evaluated for ostial dimensions, position-dependent minimal lumen area (MLA), and IML, measured by interluminal space thickness (ILS), elliptic ratio, and pericoronary fat sign. 3D-IVUS reference standard showed excellent geometric reproducibility (median point-wise distance 0.19 mm, 95%CI 0.07-0.43 mm) and good-to-excellent intrareader reliability (ICC 0.72-0.96). CCTA intra- and inter-reader reliability was moderate-to-excellent for ostial parameters and ILS-derived IML (ICC 0.69-0.92) and poor-to-good for MLA (ICC 0.28-0.87). Against 3D-IVUS, CCTA ostial area demonstrated moderate correlation (r = 0.73, p < 0.001) with minimal bias, and ILS-derived IML showed moderate agreement (r = 0.59; bias + 0.23 mm), while the fat sign substantially overestimated length (+ 7.88 mm). Using 3D-IVUS as an in-vivo reference standard for the precise assessment of coronary anatomy in AAOCA, CCTA provided reproducible ostial measurements, and the ILS-based method showed the best performance among the evaluated CCTA approaches for estimating intramural length. However, wide limits of agreement preclude precise individual sizing, and position-dependent MLA measurements remain unreliable.