In this study, we evaluated the utility of the continuous wave (CW) Doppler pre-attenuation velocity envelope as a potential surrogate for pulsed-wave (PW) Doppler-based interrogation of left ventricular outflow tract (LVOT) flow in patients with moderate or severe aortic stenosis. In a retrospective analysis, we examined 92 patients with moderate or severe aortic stenosis. Pulsed-wave Doppler was employed to acquire LVOT velocity and velocity time integral (VTI) in the 5-chamber view. CW Doppler recordings were scrutinized across multiple views with a specific focus on identifying a discernible pre-attenuation velocity envelope. Through manual tracing, we extracted peak velocity and VTI across the aortic valve as well as the pre attenuated velocity, which was used as a surrogate for LVOT assessment and substitute in the continuity equation in the evaluation of aortic valve stenosis. The pre-attenuation velocity envelope was distinctly discernible in 83 (90

This review highlights the evolving role of positron emission tomography (PET) in quantifying myocardial blood flow (MBF) and myocardial flow reserve (MFR) and its expanding clinical impact. The relative nature of perfusion assessment with single photon emission computed tomography often underestimates disease in patients with multivessel or microvascular involvement. Positron emission tomography (PET) enables absolute quantification of myocardial blood flow (MBF) and myocardial flow reserve (MFR), which provides deeper insights into coronary physiology. PET-derived MBF and MFR have shown clear diagnostic and prognostic value across a broad spectrum of conditions, including obstructive coronary artery disease, ischemia and angina without obstructive coronary artery disease, post-heart transplant cardiac allograft vasculopathy surveillance, diabetes, hypertension, and systemic inflammatory diseases. Impaired flow reserve consistently predicts adverse outcomes, even in the absence of visible perfusion defects. Newer tracers such as 18F-flurpiridaz, with their favorable kinetics and logistical advantages, are poised to expand clinical accessibility. At the same time, innovations such as artificial intelligence-driven analysis and total-body PET promise greater reproducibility and efficiency, further integrating flow assessment into everyday practice. Professional society guidelines now recommend routine incorporation of flow quantification into stress PET imaging, yet barriers remain, including limited access, heterogeneity in protocols, and a need for outcome-driven trials. As technology and evidence evolve, PET-based flow quantification is positioned to become an essential tool in precision cardiovascular care, bridging the gap between physiology and clinical decision-making.

EchocardiographyVolume 41, Issue 3 e15791 LETTER TO THE EDITOR Use of biplane echocardiographic imaging for diagnosis of left atrial appendage thrombi during transesophageal examination Roberto Ochoa Jimenez MD, Roberto Ochoa Jimenez MD Division of Cardiology, Department of Medicine, Mount Sinai Fuster Heart Hospital and the Icahn School of Medicine at Mount Sinai, New York, New York, USASearch for more papers by this authorVikram Agarwal MD, MPH, Vikram Agarwal MD, MPH Division of Cardiology, Department of Medicine, Mount Sinai Fuster Heart Hospital and the Icahn School of Medicine at Mount Sinai, New York, New York, USASearch for more papers by this authorStamatios Lerakis MD, PhD, Stamatios Lerakis MD, PhD Division of Cardiology, Department of Medicine, Mount Sinai Fuster Heart Hospital and the Icahn School of Medicine at Mount Sinai, New York, New York, USASearch for more papers by this authorEdgar Argulian MD, MPH, Corresponding Author Edgar Argulian MD, MPH [email protected] orcid.org/0000-0003-2106-2668 Division of Cardiology, Department of Medicine, Mount Sinai Fuster Heart Hospital and the Icahn School of Medicine at Mount Sinai, New York, New York, USA Correspondence Edgar Argulian MD, MPH, FACC, FASE, Division of Cardiology, Department of Medicine, Mount Sinai Morningside, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Avenue, New York, NY 10025, USA. Email:[email protected]Search for more papers by this author Roberto Ochoa Jimenez MD, Roberto Ochoa Jimenez MD Division of Cardiology, Department of Medicine, Mount Sinai Fuster Heart Hospital and the Icahn School of Medicine at Mount Sinai, New York, New York, USASearch for more papers by this authorVikram Agarwal MD, MPH, Vikram Agarwal MD, MPH Division of Cardiology, Department of Medicine, Mount Sinai Fuster Heart Hospital and the Icahn School of Medicine at Mount Sinai, New York, New York, USASearch for more papers by this authorStamatios Lerakis MD, PhD, Stamatios Lerakis MD, PhD Division of Cardiology, Department of Medicine, Mount Sinai Fuster Heart Hospital and the Icahn School of Medicine at Mount Sinai, New York, New York, USASearch for more papers by this authorEdgar Argulian MD, MPH, Corresponding Author Edgar Argulian MD, MPH [email protected] orcid.org/0000-0003-2106-2668 Division of Cardiology, Department of Medicine, Mount Sinai Fuster Heart Hospital and the Icahn School of Medicine at Mount Sinai, New York, New York, USA Correspondence Edgar Argulian MD, MPH, FACC, FASE, Division of Cardiology, Department of Medicine, Mount Sinai Morningside, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Avenue, New York, NY 10025, USA. Email:[email protected]Search for more papers by this author First published: 22 March 2024 https://doi.org/10.1111/echo.15791Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. REFERENCE 1Saric M, Armour AC, Arnaout MS, et al. Guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism. J Am Soc Echocardiogr. 2016; 29: 1-42. 10.1016/j.echo.2015.09.011 PubMedWeb of Science®Google Scholar Volume41, Issue3March 2024e15791 ReferencesRelatedInformation

Background: Coronary computed tomography angiogram (CCTA) is a crucial tool for diagnosing CAD, but its impact on altering preventive medications is not well-documented. This systematic review aimed to compare changes in aspirin and statin therapy following CCTA and functional stress testing in patients with suspected CAD, and in those underwent CCTA when stratified by the presence/absence of plaque. Results: Eight studies involving 42,812 CCTA patients and 64,118 cardiac stress testing patients were analyzed. Compared to functional testing, CCTA led to 66 % more changes in statin therapy (pooled RR, 95 % CI [1.28 -2.15]) and a 74 % increase in aspirin prescriptions (pooled RR, 95 % CI [1.34 -2.26]). For medication modi fications based on CCTA results, 13 studies (47,112 patients with statin data) and 11 studies (12,089 patients with aspirin data) were included. Patients with any plaque on CCTA were five times more likely to use or intensify statins compared to those without CAD (pooled RR, 5.40, 95 % CI [4.16 -7.00]). Significant heterogeneity remained, which decreased when stratified by diabetes rates. Aspirin use increased eightfold after plaque detection (pooled RR, 8.94 [95 % CI, 4.21 -19.01]), especially with obstructive plaque findings (pooled RR, 9.41, 95 % CI [2.80 -39.02]). Conclusion: In conclusion, CCTA resulted in higher changes in statin and aspirin therapy compared to cardiac stress testing. Detection of plaque by CCTA significantly increased statin and aspirin therapy.

Spectral Doppler examination is necessary for full hemodynamic assessment of patients with systolic heart failure. It is fully incorporated into comprehensive echocardiographic examination. In this manuscript, we describe two uncommon findings in patients with established severe left ventricular systolic dysfunction: notched aortic regurgitation and merged mitral regurgitation.

Abstract Background Cardiovascular magnetic resonance (CMR) can noninvasively identify myocardial fibrosis using extracellular volume (ECV) mapping. In patients with elevated ECV, and without hypertrophic cardiomyopathy (HCM) or cardiac amyloidosis, the prognostic significant of mild-to-moderate left ventricular hypertrophy (LVH) has not been well established. Purpose To determine if the presence of mild to moderate LVH has an impact on major adverse cardiovascular outcomes (MACE) in patients with elevated ECV without HCM or cardiac amyloidosis. Methods This was a retrospective cohort study assessing a group of patients referred for CMR between July 2019 and January 2023 to Mount Sinai Morningside. Patients with ECV>30% and left ventricular wall thickness <1.6 cm (to exclude patients with the possible diagnosis of HCM or cardiac amyloidosis) were considered for inclusion. Those with an established diagnosis of HCM or cardiac amyloidosis were also excluded. The LVH group comprised of patients with mild-to-moderate LVH, defined as a maximum wall thickness of 1.2-1.5 cm. The control group included patients without LVH (wall thickness <1.2 cm). Patients were further stratified by ECV, using the median value for our sample, as "high ECV" (≥35%) or "low ECV" (<35%). The outcome of interest was time-to-first MACE (all-cause death, or incident acute coronary syndrome, acute heart failure, or arrhythmia). Time-to-first MACE within 1 year was compared among groups using unadjusted Kaplan-Meier curves. Additional Cox regression analyses were performed to adjust for significant univariate analysis, including hypertension, hyperlipidemia, diabetes mellitus, use of beta-blocker, use of diuretic, and category of glomerular filtration rate. The results are presented as hazard ratios and 95% confidence intervals. All analyses were performed in SAS Enterprise using α<0.05. Results Out of the cohort, we identified 186 patients that met our selection criteria. The mean age was 61.1 ± 15.5 years, and 58.1% of patients were female. The median follow-up was 175 days in the control group and 115 days in the LVH group. There were 61 MACE (32.8%) in our sample. After adjusting for covariates, mild-to-moderate LVH was associated with 2.2 times the risk of MACE (95%CI 1.3 to 3.8; p=0.0047) at 1 year, compared to patients without LVH. A higher ECV (≥35%) was not significantly associated with worse outcomes within each study arm (p=0.3450). Kaplan Meier survival curves for patients with and without LVH are shown in Figure 1 (p=0.0002). Conclusions In patients with evidence of elevated ECV without underlying cardiac amyloidosis or hypertrophic cardiomyopathy, mild-to-moderate LVH is associated with 2.2 times the risk of MACE compared to normal left ventricular wall thickness.Figure 1

A 34-year-old female who was recently placed on anti-tuberculosis medication with rifampin, isoniazid, pyrazinamide, and levofloxacin therapy for suspected tuberculosis reinfection presented with subjective fevers, rash, and generalized fatigue. Labs showed signs of end-organ damage with eosinophilia and leukocytosis. One day later, the patient became hypotensive with a worsening fever, and an electrocardiogram showed new diffuse ST segment elevations with an elevated troponin. An echocardiogram revealed a reduction in ejection fraction with diffuse hypokinesis, and cardiac magnetic resonance imaging (MRI) showed circumferential myocardial edema with subepicardial and pericardial inflammation. Prompt diagnosis of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome using the European Registry of Severe Cutaneous Adverse Reaction (RegiSCAR) criteria and discontinuation of therapy was initiated. Due to the hemodynamic instability of the patient, the patient was started on systemic corticosteroids and cyclosporine, with the improvement of her symptoms and rash. A skin biopsy was performed, which revealed perivascular lymphocytic dermatitis, consistent with DRESS syndrome. As the patient's ejection fraction improved spontaneously with corticosteroids, the patient was discharged with oral corticosteroids, and a repeat echocardiogram showed full recovery of ejection fraction. Perimyocarditis is a rare complication of DRESS syndrome that is associated with degranulation and the release of cytotoxic agents into myocardial cells. Early discontinuation of offending agents and initiation of corticosteroids are essential to rapid recovery of ejection fraction and improved clinical outcomes. Multimodality imaging, including MRI, should be used to confirm perimyocardial involvement and guide the necessity for mechanical support or transplant. Further research should be on the mortality of DRESS syndrome with and without myocardial involvement, with an increased emphasis on cardiac evaluation in DRESS syndrome.

ABSTRACT ATTR-CA is an under-reported cause of congestive heart failure (CHF) and cardiac arrhythmias. Heightened clinical suspicion along with a multimodal investigative approach is often required in diagnosing this potentially fatal condition. Tafamidis and inotersen have shown promising results in terms of progression-free survival by ameliorating CHF symptoms and peripheral neuropathies in clinical trials. In this case series of five patients, we present three wild-type cardiac amyloidosis (ATTRwt-CA), one familial cardiac amyloidosis (ATTRm-CA) and one primary cardiac (AL-CA). The diagnostic modality was different for each patient. ATTRwt-CA, ATTRm-CA and AL-CA patients received tafamidis, inotersen and chemotherapy with bone marrow stem-cell transplantation, respectively.

Amyloidosis is caused by deposition of misfolded insoluble beta-pleated sheets into the extracellular space. The diagnosis of cardiac amyloidosis could be challenging and often underreported. In this case series of 5 patients, we present three ATTRwt or senile amyloidosis, one ATTRm or familial

Takotsubo cardiomyopathy (TTC) is a clinical syndrome that closely mimics acute coronary syndrome (ACS) and presents with chest pain and dyspnea, dynamic ST/T changes, elevated myocardial necrosis biomarkers, and regional left ventricular wall motion abnormalities, without significant coronary

Although the presence of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance imaging (CMR) is a significant discriminator of events in patients with suspected myocarditis, no data are available on the optimal LGE quantification method. Six hundred seventy consecutive patients (48 ± 16 years, 59% male) with suspected myocarditis were enrolled between 2002 and 2015. We performed LGE quantitation using seven different signal intensity thresholding methods based either on 2, 3, 4, 5, 6, 7 standard deviations (SD) above remote myocardium or full width at half maximum (FWHM). In addition, a LGE visual presence score (LGE-VPS) (LGE present/absent in each segment) was assessed. For each of these methods, the strength of association of LGE results with major adverse cardiac events (MACE) was determined. Inter-and intra-rater variability using intraclass-correlation coefficient (ICC) was performed for all methods. Ninety-eight (15%) patients experienced a MACE at a medium follow-up of 4.7 years. LGE quantification by FWHM, 2- and 3-SD demonstrated univariable association with MACE (hazard ratio [HR] 1.05, 95% confidence interval [CI]:1.02–1.08, p = 0.001; HR 1.02, 95%CI:1.00–1.04; p = 0.001; HR 1.02, 95%CI: 1.00–1.05, p = 0.035, respectively), whereas 4-SD through 7-SD methods did not reach significant association. LGE-VPS also demonstrated association with MACE (HR 1.09, 95%CI: 1.04–1.15, p < 0.001). In the multivariable model, FWHM, 2-SD methods, and LGE-VPS each demonstrated significant association with MACE adjusted to age, sex, BMI and LVEF (adjusted HR of 1.04, 1.02, and 1.07; p = 0.009, p = 0.035; and p = 0.005, respectively). In these, FWHM and LGE-VPS had the highest degrees of inter and intra-rater reproducibility based on their high ICC values. FWHM is the optimal semi-automated quantification method in risk-stratifying patients with suspected myocarditis, demonstrating the strongest association with MACE and the highest technical consistency. Visual LGE scoring is a reliable alternative method and is associated with a comparable association with MACE and reproducibility in these patients. NCT03470571 . Registered 13th March 2018. Retrospectively registered.

Subacute tamponade is a challenging diagnosis requiring careful consideration of both clinical and imaging data. We aimed at exploring the association of initial blood pressure with markers of pericardial effusion severity in patients with moderate and large pericardial effusion. We conducted a retrospective, single-center study in 102 well-phenotyped patients with moderate and large pericardial effusion. The presenting systolic and diastolic blood pressure recordings were divided into tertiles to examine the association between the blood pressure and the different established markers of pericardial effusion severity. On presentation, 42% of patients had systolic blood pressure exceeding 130 mm Hg, and only 5% of patients had systolic blood pressure <90 mm Hg. Patients in the lowest blood pressure tertiles did not differ significantly from patients in the upper tertiles in terms of clinical, etiologic, or echocardiographic characteristics. Although patients who underwent pericardial drainage had higher presenting heart rates, no significant differences were seen in the blood pressure recordings, either systolic or diastolic (mean 125 mm Hg vs 130 mm Hg, p = 0.36 and 76 vs 75 mm Hg, p = 0.82, respectively). In conclusion, systolic and diastolic blood pressure recordings upon initial presentation do not demonstrate a significant association with markers of effusion severity or the need for drainage in patients with moderate and large pericardial effusion. (C) 2018 Elsevier Inc. All rights reserved.

Cardiovascular magnetic resonance imaging (CMR) has become a key investigative tool in patients with suspected myocarditis. However, the prognostic implications of T1 mapping, including extracellular volume (ECV) calculation, is less clear. Patients with suspected myocarditis who underwent CMR evaluation, including T1 mapping at our institution were included. CMR findings including late gadolinium enhancement (LGE), left ventricular ejection fraction (LVEF), native T1 mapping, and ECV calculation were associated with first major adverse cardiac events (MACE). MACE included a composite of all-cause death, heart failure hospitalization, heart transplantation, documented sustained ventricular arrhythmia, and recurrent myocarditis. One hundred seventy-nine patients with a mean age of 49 ± 15 years were identified. Seventy nine individuals (44%) were female. Mean LVEF was 48 ± 16. At a median follow-up of 4.1 [interquartile-range (IQR) 2.2–6.1] years, 22 (12%) patients experienced a MACE. Mean ECV (per 10%) was significantly associated with MACE (HR 2.09, 95% CI 1.07–4.08, p = 0.031). Presence of ECV ≥ 35% demonstrated significant univariable association with MACE (HR 3.3, 95% CI 1.43–7.97, p = 0.005) and such association was maintained when adjusted to LVEF (HR 3.42, 95% CI 1.42–7.94, p = 0.006). ECV ≥ 35% portended a greater than threefold increased hazards to MACE adjusted to LGE presence (HR 3.14, 95% CI 1.29–7.36, p = 0.012). In patients without LGE, ECV ≥ 35% portended a greater than sixfold increased hazards (HR 6.6, p = 0.010). In the multivariable model including age, LVEF and LGE size, only ECV ≥ 35% maintained its significant association with outcome. ECV calculation by CMR is a useful tool in the risk stratification of patients with clinically suspected myocarditis, incremental to LGE and LVEF.

There is accumulating evidence for the existence of a phenotype of isolated cardiac sarcoidosis (ICS), or sarcoidosis that only involves the heart. In the absence of biopsy-confirmed cardiac sarcoidosis (CS), existing diagnostic criteria require the presence of extra-cardiac sarcoidosis as an inclusion criterion for the diagnosis of CS. Consequently, in the absence of a positive endomyocardial biopsy, ICS is not diagnosable by current guidelines. Therefore, there is uncertainty regarding the epidemiology, pathobiology, clinical characteristics, prognosis, and optimal treatment of ICS. This review will summarize the available data related to the prevalence and prognosis of ICS and will discuss challenges surrounding the diagnosis and management of this under-recognized entity.

This review aims to provide an overview of how cardiovascular imaging can help individualize preventive cardiovascular care, while focusing on the implications of various recent noninvasive and invasive imaging studies for the field of preventive cardiology.