BACKGROUND:Pericarditis is typically diagnosed on the basis of clinical criteria (chest pain, pericardial rub, ECG changes and pericardial effusion). However, the diagnosis can be challenging as these findings are often transient. We evaluated the clinical utility of cardiac magnetic resonance (CMR) in the diagnosis of pericarditis. METHODS:Consecutive patients referred for the evaluation of pericarditis by CMR between 2010 and 2024 to a tertiary hospital in Sydney, Australia, were retrospectively screened. Patients were stratified according to the presence (CMR-pos) or absence (CMR-neg) of pericardial late gadolinium enhancement (LGE) and analysed for differences in clinical patterns, C reactive protein (CRP), troponin and imaging findings. RESULTS:Among 2530 patients referred for CMR, 88 patients (age 39 years (IQR 24-52), 37% female) were identified as referrals for pericarditis/myopericarditis. 43/88 (49%) patients had CMR-proven pericarditis and 45/88 (51%) did not. Among CMR-pos patients, 13/43 (30%) did not meet 2015 ESC diagnostic criteria. Conversely, 24/45 (47%) CMR-neg patients met criteria for a clinical diagnosis. CRP and pericardial effusion were associated with positive scans and more severe pericardial disease (CRP 178 mg/L (IQR 98-253) and 88% had pericardial effusion in moderate/severe pericardial LGE vs 35 mg/L (IQR 7-63) and 19% in minimal/mild, p<0.05 for both). CRP level demonstrated moderate predictive value for identifying CMR-pos scans with a sensitivity of 56% and a specificity of 84% for CRP levels above 50 mg/L. CMR-pos patients not meeting clinical criteria tended to have more subacute and non-idiopathic disease despite similar levels of pericardial LGE when compared with those with clinically apparent pericarditis. CONCLUSIONS:CMR reliably identifies pericardial inflammation in patients not meeting clinical criteria and excludes significant inflammation in a large proportion of patients with an initial clinical diagnosis. CRP level and the presence of pericardial effusion may help identify patients who are likely to have CMR evidence of pericarditis.

INTRODUCTION:Stiff left atrium (LA) is important in the pathophysiology and progression of heart failure with preserved ejection fraction. Non-invasive techniques used to measure stiff LA have significant limitations. Prominent V waves seen during right heart catheterisation (RHC) have been linked to a stiff LA; however, there are no studies exploring the prevalence of this in patients with pulmonary hypertension (PH). We present the first study assessing stiff LA using invasive techniques in patients with PH using V wave measurements on RHC. METHODS:50 patients with PH (66.9±14.5 years, 30% male) and 18 controls were studied. Patients with left ventricular (LV) dysfunction, moderate or greater mitral regurgitation or atrial fibrillation were excluded. Echocardiographic (LA area, E/E' average, LV hypertrophy) and RHC (peak/mean pulmonary artery pressures, mean pulmonary capillary wedge pressure (mPCWP), V wave) parameters were collected. Prominent V wave was defined as ≥10 mm Hg above mPCWP. Prevalence of prominent V waves and its correlations between echocardiographic and RHC parameters were determined. RESULTS:Six (12%) patients with PH had prominent V waves, while none of the control patients did (12% vs 0%, respectively, p=0.18). Prominent V waves were only seen in patients with postcapillary PH (28.6% vs 0%; p=0.003) and were strongly associated with echocardiographic parameters-LA size and E/E' ratio. CONCLUSIONS:Prominent V waves, a marker of stiff LA, can be easily and readily assessed by RHC and are common with postcapillary PH. Larger studies are needed to elucidate its clinical implications.

Parvovirus B19, pathogen of children’s fifths disease, is among the causes of viral/idiopathic pericarditis. This paper presents 3 adult cases of complicated effusive-constrictive parvovirus B19 pericarditis presenting with overt diastolic heart failure during an outbreak in September to October 2023. Comprehensive transthoracic echocardiography and cardiac magnetic resonance played a key role in noninvasive assessment of constrictive physiology and pericardial inflammation, guiding successful treatment with low-dose prednisolone, having failed standard colchicine and nonsteroidal anti-inflammatory drugs.

•Pressure-regulated deployment (PRD) results in consistent and excellent transcatheter aortic valve (TAV) performance.•PRD produces superior valve hemodynamics in patients with small aortic annuli.•PRD mitigates the risk of annular injury even among patients at high anatomic risk.•PRD enables effective implantation of larger TAV in border-zone valve sizing cases.

BACKGROUND:It is unknown whether the degree of high-sensitivity troponin T (hsTropT) elevation in patients with suspected myocardial infarction without obstructive coronary arteries (MINOCA) presentations can help predict the likelihood of an abnormal cardiac magnetic resonance (CMR) scan. In this study we describe the diagnostic utility of CMR in patients with MINOCA and assesses the effect of peak hsTropT levels at presentation on CMR diagnostic yield. METHODS:Records of consecutive patients (n = 1407) referred for CMR at a tertiary referral hospital between January 2016 and September 2021 were reviewed. A total of 70 patients met the criteria of MINOCA including ischemic chest pain, elevated peak hsTropT, and nonobstructive coronary artery disease (< 50% stenosis). The peak hsTropT levels within 72 hours of admission were identified. CMR images were generated using a 3.0 T Siemens scanner. Predictors of having an abnormal CMR were evaluated. RESULTS:CMR established a diagnosis in 71% (n = 50) of patients, with the most common CMR diagnosis being myopericarditis (n = 27; 39%). Time to CMR was an independent predictor of a normal CMR scan (odds ratio, 0.98; 95% confidence interval, 0.97-0.999). Peak hsTropT had a high diagnostic accuracy for identifying patients with an abnormal CMR scan (area under the receiver operator characteristic curve, 0.81; P < 0.001). The optimal hsTropT cutoff was 166 ng/L, with 72% sensitivity and specificity. A troponin value ≥ 166 ng/L was independently predictive of an abnormal CMR scan (odds ratio, 4.76; 95% confidence interval, 1.32-17.11). CONCLUSIONS:HsTropT and early CMR imaging are independently predictive of an abnormal CMR scan in patients with MINOCA. Additionally, the use of a hsTropT cutoff provides incremental predictive value to clinical parameters and time to CMR scanning in determining an abnormal scan.

The burden of cardiac disease in patients with muscular dystrophy (MD) is high and includes cardiomyopathy, conduction abnormalities, and sudden cardiac death. This study examined the utility of cardiac magnetic resonance imaging (CMR) in this cohort, including the added value beyond routine transthoracic echocardiography (TTE). Patients at a single tertiary referral centre for MD who had undergone transthoracic echocardiography (TTE) and CMR were retrospectively analysed. The prevalence and range of CMR abnormalities were assessed in this cohort. Twenty patients with six different subtypes of MD underwent CMR between 2016 and 2020. Mean age was 39.6±13.4 years and 16 of 20 (80%) were male. The MD subgroups included Myotonic (n=10), Limb Girdle (n=3), Duchenne (n=3), Becker (n=2), Central Core (n=1), and Facioscapulohumeral (n=1). Structural abnormalities were detected in 15 of 20 (75%) patients. These included abnormal late gadolinium enhancement (LGE) in a non-ischaemic pattern, predominantly in the lateral and inferolateral wall (11 of 20, 55%) and abnormal ventricular function and/or volumes in 10 of 20 (50%). Among 10 patients with a normal TTE (normal biventricular volumes and function, and no regional wall motion abnormality) CMR demonstrated LGE in five of 10 (50%) patients (2 of 5 Myotonic, 2 of 5 Limb Girdle, and 1 of 5 Becker), two of whom also had mildly impaired left ventricular ejection fraction by CMR quantification. Cardiac magnetic resonance imaging abnormalities are prevalent in patients with MD. Additionally, CMR provides significant added value in this cohort by detecting structural abnormalities in approximately half of patients with a seemingly normal TTE.

•Aortic fistulas are a rare complication in patients undergoing balloon expandable TAVI.•Subannular calcification and excessive postdilation can cause ARV fistula formation.•Prompt imaging to quantify the shunt allows for planning and management of these cases.•Smaller, hemodynamically stable shunts can be managed conservatively.•Surgical repair is standard, but percutaneous closure is achievable with TEE guidance.

A recent publication in Respirology examined the relationship between cardiovascular disease and airways disease, demonstrating that patients who had a cardiovascular event following a moderate- or severe exacerbation of asthma had a higher risk of mortality.1 The patients were older, and although age was adjusted for in the analysis, the presence of smoking was not reported. Cardiovascular disease and major adverse cardiovascular events (MACE) are also common in patients with bronchiectasis.2 All-cause mortality increases with increasing severity of bronchiectasis. Some of this increase in mortality may be related to cardiovascular disease. Coronary artery calcium (CAC) is associated in a graded fashion with the risk of atherosclerotic cardiovascular disease and MACE, independent of traditional risk factors.3 Since many patients with bronchiectasis have chest CTs for diagnosis, disease monitoring and assessment of acute exacerbations, CAC scoring could provide opportunistic cardiac risk assessment and risk reduction to this cohort of patients. Recent international guidelines4 suggest routine reporting of CAC on all non-gated non-contrast CT chest examinations. In the era of lung cancer screening it is likely that we will detect CAC in patients with both asthma and bronchiectasis. The standardization of reporting of chest CTs to include CAC could be an opportunity for expanding CAC as a marker of comorbidity in a ‘treatable traits’ approach to reducing mortality risk for patients with airways disease. We retrospectively measured CAC on CT scans of 155 patients (108 females, mean age 66 ± 16 years) in the Australian Bronchiectasis Registry. Patients were stratified in terms of risk categories (nil, mild, moderate or severe) based on CAC quantification. Bronchiectasis severity was calculated using the FACED score. Somers' delta test was used to assess the association between FACED and CAC score. Bronchiectasis severity was mild in 49%, moderate in 38% and severe in 13%. Most patients (61%) had evidence of coronary calcification (27% mild, 20% moderate and 14% severe calcification). There was no difference in cardiovascular comorbidity or medications between patients with varying bronchiectasis severity. The rate of smoking was significantly higher in patients with higher CAC and FACED scores. There was a positive association between FACED score and CAC risk score, d = 0.259, p = 0.001 (Figure 1). This remained significant when stratified for smoking status. Bronchiectasis severity is associated with increased coronary artery calcium, and therefore cardiac risk, even in never-smokers. We were surprised that this association was not stronger given the fact that severity of bronchiectasis using FACED criteria is strongly correlated with exacerbation frequency and systemic inflammation. It is worth noting that only a minority of patients (13%) had severe bronchiectasis, which may have led to an underestimation of the impact of bronchiectasis severity and inflammation on cardiac risk. Despite having non-severe bronchiectasis, most patients had evidence of CAC which indicates an independent increase in cardiovascular risk that we can easily and non-invasively measure. This represents a significant population of patients with bronchiectasis who would be anticipated to benefit from early initiation of cardioprotective treatment and subsequent risk reduction. Lewis Holmes: Conceptualization (equal); data curation (lead); formal analysis (lead); investigation (equal); methodology (equal); project administration (equal); writing – original draft (lead); writing – review and editing (lead). Isaac Lui: Data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); writing – original draft (supporting); writing – review and editing (equal). Paul Lilburn: Conceptualization (equal); data curation (equal); methodology (equal); project administration (equal); writing – review and editing (equal). Christopher Naoum: Investigation (equal); methodology (equal); writing – review and editing (equal). Leonard Kritharides: Methodology (equal); supervision (equal); writing – review and editing (equal). Lloyd Ridley: Formal analysis (equal); investigation (equal); methodology (equal); project administration (equal); supervision (equal); writing – review and editing (equal). Lucy Morgan: Conceptualization (lead); data curation (lead); formal analysis (equal); funding acquisition (equal); investigation (equal); methodology (equal); project administration (equal); supervision (lead); writing – original draft (equal); writing – review and editing (equal). Lucy Morgan receives speaking fees from Zambon, Insmed, AstraZeneca, Novartis and GSK and grant funding from Boehringer Ingelheim, Novartis and AstraZeneca. Leonard Kritharides receives consulting fees from Seqirus and speaking fees from Novartis and Limbic. Lloyd Ridley receives speaking fees from AstraZeneca. The other authors report no significant conflicts of interest relating to this manuscript. The Australian Bronchiectasis Registry where the data was collected from has National research ethics approval (Protocol No. X16-0382, Project No. HREC/15/CRGH/225). Further approval for this study was obtained from the local institutional review board CH62/6/2018-209. The data that support the findings of this study are available from the corresponding author upon reasonable request.

PurposeIn this cohort study, 5-year data from the Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry (ie, CONFIRM) were examined to identify associations of baseline aspirin and statin use with mortality, major adverse cardiovascular events (MACE), and myocardial infarction (MI) in individuals without substantial (≥50%) stenosis.Materials and MethodsIn this prospective cohort study, all participants in the registry underwent coronary CT angiography and were classified as having no detectable coronary plaque or having nonobstructive coronary artery disease (CAD) (1%-49% stenosis). Participants with obstructive (≥50%) stenosis were excluded from analysis. The study commenced in June 2003 and was completed in March 2016. All unadjusted and risk-adjusted analyses utilized the Cox proportional hazard model with hospital sites modeled using shared frailty.ResultsA total of 6386 participants with no detectable plaque or with nonobstructive CAD were included (mean age, 56.0 years ± 13.3 [SD], 52% men). The mean follow-up period was 5.66 years ± 1.10. Nonobstructive CAD (n = 2815, 44% of all participants included in the study) was associated with a greater risk of all-cause mortality (10.6% [298 of 2815] vs 4.8% [170 of 3571], P < .001) compared to those without CAD (n = 3571, 56%). Baseline aspirin and statin use was documented for 1415 and 1429 participants, respectively, with nonobstructive CAD, and for 1560 and 1565 participants without detectable plaque, respectively. In individuals with nonobstructive CAD, baseline aspirin use was not associated with a reduction in MACE (10.9% [102 of 936] vs 14.7% [52 of 355], P = .06), all-cause mortality (9.6% [95 of 991] vs 10.9% [46 of 424], P = .468), or MI (4.4% [41 of 936] vs 6.2% [22 of 355], P = .18). On multivariate risk-adjusted analysis, baseline statin use was associated with a lower rate of MACE (hazard ratio, 0.59; 95% CI: 0.40, 0.87; P = .007). Neither therapy improved clinical outcomes for participants with no detectable plaque.ConclusionIn participants with nonobstructive CAD, baseline use of statins, but not of aspirin, was associated with improved clinical outcomes. Neither therapy was associated with benefit in participants without plaque.Keywords: Aspirin, Statin, Coronary Artery Disease, CT Angiography, Nonobstructive Coronary Artery DiseaseClinical trial registration no. NCT01443637 Supplemental material is available for this article. © RSNA, 2022See also the commentary by Canan and Navar in this issue.

Acute myocarditis (AM) is uncommon but may be associated with significant acute deterioration, requiring emergency high-level tertiary level care. We therefore sought to examine the contemporary management of myocarditis presenting to a rural referral centre, comparing this to a recently proposed "risk-based approach" [1], providing a framework based on risk of deterioration, to help select those requiring transfer for tertiary level care.

BACKGROUND:Functional mitral regurgitation (FMR) occurs in patients with annular dilation (atrial, aFMR) or patients with left ventricular (LV) disease (ventricular, vFMR). Meticulous understanding of the mechanisms underpinning regurgitation is crucial to optimize therapeutic strategies. METHODS:Patients with moderate-severe FMR were identified from a registry of patients referred for transcatheter mitral valve intervention. In addition, controls without cardiovascular disease were identified. Differences in the geometry of the LV and mitral valve apparatus (including leaflet and tenting geometry, papillary muscle displacement and movement, annular dimensions, and dynamism) between atrial and ventricular FMR, and control subjects, were assessed using multiphasic cardiac CT. RESULTS:Of 183 FMR patients, 18 patients (10%) were found to have aFMR. The remaining patients had either ischemic or non-ischemic ventricular FMR. In aFMR, both increasing LV end-systolic volume (rho 0.701, p ​< ​0.01) and left atrial volume (rho 0.909, p ​< ​0.01) were associated with larger annular area. By contrast, in vFMR larger annular area was most strongly associated with larger left atrial volume (rho 0.63, p ​< ​0.01). In controls, increased annular area was associated with larger LVEDV (rho 0.78, p ​< ​0.01) and LVESV (rho 0.824, p ​< ​0.01), but not left atrial size (rho 0.16, p ​= ​0.45). Ventricular FMR comprised apicolaterally displaced, akinetic posteromedial papillary muscles, resulting in pronounced leaflet tethering, leaflet elongation compared to controls, and only modest relative LA dilatation. Compared to vFMR, aFMR was characterised by marked relative annular dilation, smaller but discernible mitral valve tenting, shorter leaflet lengths when related to annular size, but normal papillary geometry. CONCLUSION:FMR is characterised by multiple changes within the mitral valve complex. Atrial and ventricular FMR differ significantly in terms of the drivers of annular size, and geometry and function of the subvalvular apparatus. This highlights the need to consider these as separate disease entities.

Background: Despite historically being considered a channelopathy, subtle structural changes have been reported in Brugada syndrome (BrS) on histopathology and cardiac magnetic resonance (CMR) imaging. It is not known if these structural changes progress over time. Objective: The study sought to assess if structural changes in BrS evolve over time with serial CMR assessment and to investigate the utility of parametric mapping techniques to identify diffuse fibrosis in BrS. Methods: Patients with a diagnosis of BrS based on international guidelines and normal CMR at least 3 years prior to the study period were invited to undergo repeat CMR. CMR images were analyzed de novo and compared at baseline and follow-up. Results: Eighteen patients with BrS (72% men; mean age at follow-up 47.4 ± 8.9 years) underwent serial CMR with an average of 5.0 ± 1.7 years between scans. No patients had late gadolinium enhancement (LGE) on baseline CMR, but 4 (22%) developed LGE on follow-up, typically localized to the right ventricular (RV) side of the basal septum. RV end-systolic volume increased over time (P = .04) and was associated with a trend toward reduction in RV ejection fraction (P = .07). Four patients showed a reduction in RV ejection fraction >10%. There was no evidence of diffuse myocardial fibrosis observed on parametric mapping. Conclusions: Structural changes may evolve over time with development of focal fibrosis, evidenced by LGE on CMR in a significant proportion of patients with BrS. These findings have implications for our understanding of the pathological substrate in BrS and the longitudinal evaluation of patients with BrS.

Background:IgG4-related disease (IgG4-RD) is an autoimmune condition affecting almost every organ system, with an early inflammatory phase and later fibrotic consequences. Vascular manifestations, particularly, large-vessel involvement in IgG4-RD, are well described. However, important IgG4-related effects on medium-sized arteries and the pericardium are less well recognized. These less frequently reported cardiovascular effects of IgG4-RD include coronary artery stenosis, pericardial disease, cardiac masses, and valvular heart disease. Case summary:This case series focuses on three patients that demonstrate the cardiovascular effects of IgG4-RD and the pitfalls and importance of early diagnosis. Cases 1 and 2 presented with cardiac manifestations prior to more typical organ systems being affected which led to a delay in diagnosis. Case 1 presented with an acute myocardial infarction secondary to IgG4-RD of the coronary arteries and Case 2 presented with pericarditis which progressed to pericardial constriction due to IgG4-RD. Case 3 already had a diagnosis of IgG4-RD from a prior renal biopsy which raised the index of suspicion that his pericardial disease and thoracic mass were also related to IgG4-RD. Discussion:Cardiac manifestations of IgG4-RD remain under-recognized and include coronary artery and pericardial disease. These manifestations often precede more typical manifestations in other organ systems. Recognizing cardiac manifestations of IgG4-RD on cardiac imaging can raise clinical suspicion and act as a catalyst to ascertain a confirmatory diagnosis. Early diagnosis and treatment are crucial to prevent potentially fatal outcomes and irreversible fibrosis.

Giant coronary artery aneurysms are a rare manifestation of coronary artery disease and are defined by an aneurysmal diameter of >20 mm. Multimodal invasive and noninvasive imaging is required for accurate assessment We describe a case of multivessel giant coronary artery aneurysms noted during angiography for myocardial infarction. (Level of Difficulty: Intermediate.)

BackgroundCoronary artery calcium (CAC) identified on non-gated CT scan of the chest is predictive of major adverse cardiac events (MACE) in multiple studies with guidelines therefore recommending the routine reporting of incidental CAC. These studies have been limited however to the outpatient setting. We aimed to determine the prognostic utility of incidentally identified CAC on CT scan of the chest among hospital inpatients.Methods and resultsConsecutive patients (n=740) referred for inpatient non-contrast CT scan of the chest at a tertiary referral hospital (January 2011 to March 2017) were included (n=280) if they had no known history of coronary artery disease, active malignancy or died within 30 days of admission. Scans were assessed for the presence of CAC by visual assessment and quantified by Agatston scoring. Median age was 69 years (IQR: 54–82) and 51% were male with a median CAC score of 7 (IQR 0–205). MACE occurred in 140 (50%) patients at 3.5 years median follow-up including 98 deaths. Half of all events occurred within 18 months. Visible CAC was associated with increased MACE (HR) 6.0 (95% CI: 3.7 to 9.7) compared with patients with no visible CAC. This finding persisted after adjusting for cardiovascular risk factors HR 2.4 (95% CI: 1.3 to 4.3) and with both absolute CAC score and CAC score ≥50th percentile.ConclusionIncidental CAC identified on CT scan of the chest among hospital inpatients provides prognostic information that is independent of cardiovascular risk factors. These patients may benefit from aggressive risk factor modification given the high event rate in the short term.

Australian guidelines recommend prompt evaluation of patients presenting to emergency departments with chest pain, found to be low risk for acute coronary syndromes, and cardiologist-led Rapid Access Chest Pain Clinics (RACPC) have been proposed as a model to provide such care. Initial Australian experience of RACPCs suggests excellent short-term outcomes, and that they are cost-beneficial, though little data exists examining longer-term outcomes. The present study therefore examines such longer-term outcomes to beyond 5 years following presentation to an RACPC in an Australian tertiary metropolitan centre.