Background New nonclinical parameters are needed to improve the current stroke risk stratification schemes for patients with atrial fibrillation. This study aimed to summarize data on potential cardiac imaging correlates and predictors of stroke or systemic embolism in patients with atrial fibrillation. Methods MEDLINE, EMBASE, and Web of Science were searched to identify all published studies providing relevant data through 16 November 2022. Random effects meta-analysis method was used to pool estimates. Results We included 64 studies reporting data from a pooled population of 56 639 patients. Left atrial spontaneous echo-contrast [adjusted odds ratio (aOR) 3.32, 95% confidence interval (CI) 1.98–5.49], nonchicken wing left atrial appendage (LAA) morphology (aOR 2.15, 95% CI 1.11–4.18), left atrial enlargement (aOR 2.12, 95% CI 1.45–3.08), and higher LAA orifice diameter (aOR 1.56, 95% CI 1.18–2.05) were highly associated with stroke. Other parameters associated with stroke included higher left atrial sphericity (aOR 1.14, 95% CI 1.01–1.29), higher left atrial volume (aOR 1.03, 95% CI 1.01–1.04), higher left atrial volume index (aOR 1.014, 95% CI 1.004–1.023), lower left atrial reservoir strain [adjusted hazard ratio (aHR) 0.86, 95% CI 0.76–0.98], higher left ventricular mass index (aOR 1.010, 95% CI 1.005–1.015) and E / e’ ratio (aOR 1.12, 95% CI 1.07–1.16). There was no association between LAA volume (aOR 1.37, 95% CI 0.85–2.21) and stroke. Conclusion These cardiac imaging parameters identified as potential predictors of thromboembolism may improve the accuracy of stroke risk stratification schemes in patients with atrial fibrillation. Further studies should evaluate the performance of holistic risk scores including clinical factors, biomarkers, and cardiac imaging.

Low female participant representation in clinical trials is poorly understood. One postulated explanation is bias through imbalance in trial leadership gender. This study examined the association between staff and participant gender in an Australian cohort of two contemporary multicentre heart failure trials. Twelve Australian centres provided gender data. Participant, principal investigator, consenting investigator, and trial coordinator genders were recorded. Analysis was performed by Pearson Chi-squared testing via SPSS; p-values of <0.05 was considered significant. This study examined 179 participants: 37 women (20.7%) and 142 men (79.3%). The principal investigator was female at four sites (30%). The trial coordinator was female at 10 sites (83%). The consenting investigator was female for 78 subjects (43.6%) and male for 101 (56.4%). No association was found between principal investigator and participant gender (0.087; p=0.77) or consenting investigator and participant gender (0.002; p=0.96). There was a trend against female participation when the trial coordinator was female (3.07; p=0.08). Low female participant representation in clinical trials remains an important, poorly understood, and emotive issue. This study found no association between principal or consenting investigator, and participant gender. The signal for the consenting trial coordinator was unexpected and warrants further consideration. Further prospective analyses are needed to explore participant gender imbalance in clinical trials, including both reasons for "screen failures" and participants' reasons to decline enrolment.

Giant cell myocarditis (GCM) is a rare, often rapidly progressive form of myocarditis characterised by frequent progression to refractory heart failure, cardiogenic shock, ventricular arrhythmia, and need for cardiac transplantation. However, very few reports highlight GCM as a potential ST-elevation myocardial infarction (STEMI) mimic. A previously well 51-year-old male presented to a tertiary hospital with a 2-day history of fever, dyspnoea, and chest pain. Initial electrocardiogram demonstrated inferolateral ST-elevation (Figure); hence, emergent coronary angiography was undertaken, demonstrating non-obstructive coronary arteries. Transthoracic echocardiography revealed severe, global left-ventricular systolic dysfunction. On admission day 2, he developed cardiogenic shock requiring escalation of care to the intensive care unit. Cardiac MRI demonstrated diffuse myocardial oedema with extensive, diffuse late gadolinium enhancement in sub-epicardial to mid-myocardial distribution suggestive of acute fulminant myocarditis. Endomyocardial biopsy revealed a mixed inflammatory infiltrate of multinucleate giant cells, associated eosinophils, reactive fibroblasts, and scattered lymphocytes involving the myocardium, confirming the diagnosis of GCM. Early immunosuppressive treatment with high-dose steroids, mycophenolate, and tacrolimus was initiated, resulting in stabilisation of haemodynamic parameters and moderate improvement of ventricular function. Heart failure-directed medical therapy was also initiated. Despite these treatments, the patient clinically declined and an orthotopic cardiac transplant was undertaken 6 months post index admission. He has remained well at 12-months follow-up without disease recurrence. Whilst presentations of chest pain and ST-elevation should prompt rapid treatment for presumptive STEMI, this case highlights acute, fulminant GCM as a rare but important STEMI mimic, particularly in individuals who develop cardiogenic shock.

Systemic sclerosis (SSc) has the highest mortality of autoimmune diseases. Pulmonary arterial hypertension (PAH) occurs in 8%–12% of SSc patients. Patients with SSc are screened annually with various tools (including transthoracic echocardiography) and right heart catheterisation (RHC) is indicated if positively screened. While these algorithms are highly sensitive for the detection of PAH, specificity is only moderate. Right ventricular free wall systolic strain (RVFWSS) has been shown to predict clinical deterioration and mortality in established PAH; however, its role in prediction of PAH in SSc is unknown.

Cardiac involvement in systemic sclerosis (SSc) is an important negative prognostic factor, which can be challenging to detect and evidence when optimal treatment is lacking. A 39-year-old man presented with a history of limited SSc, initially displaying typical features including Raynaud's phenomenon, digital ulceration, calcinosis, sclerodactyly, arthralgias, and gastro-oesophageal reflux disease. Cardiac involvement manifested 7 years after diagnosis when presenting with new atrial fibrillation and flutter requiring ablation. Autoantibody testing was significant for a positive ANA (1:1,280) and weak positive RF (15 IU/mL), but negative anti-RNA polymerase III Ab, anti-Scl 70 Ab, and anti-centromere Ab. Cardiac magnetic resonance imaging (CMR) revealed mild ventricular dilatation and mild hypokinesis of the basal-to-mid anteroseptum. Native T2 and T1 mapping values were elevated, with colour maps suggestive of diffuse septal involvement (Global T1, 1,155 ms; inferoseptal T1, 1,150 ms; inferoseptal T2, 62 ms). Late gadolinium-enhancement (LGE) was also present at this location, suggestive of focal fibrosis or inflammation. Endomyocardial biopsy was subsequently performed, which revealed evidence of patchy interstitial and perivascular fibrosis with small vessel mural thickening, consistent with cardiac involvement from SSc. Immunosuppressive treatment was commenced with prednisolone, intravenous cyclophosphamide, and mycophenolate. Following eight cycles of cyclophosphamide, the CMR demonstrated resolution of myocardial LGE and a reduction in Native myocardial T1 relaxation time to 1032±35 ms (global value). This case highlights a concerning case of a young man with SSc-related cardiac pathology, presenting with cardiac arrythmia. Treatment with cyclophosphamide-based immunosuppression resulted in clinical and radiological improvement of cardiac disease.

The use of mRNA COVID-19 vaccine can on rare occasions cause life-threatening, fulminant myopericarditis. This case report demonstrates previously reported benefit of early use of venoarterial extracorporeal membrane oxygenation mechanical assistance and supports the use of intravenous highly purified immunoglobulin pharmacotherapy to help achieve a good clinical outcome.

Methamphetamine-associated cardiomyopathy (MA-CMP) is an increasingly recognised aetiology of cardiomyopathy. Cardiovascular magnetic resonance (CMR) is a specialised cardiac imaging modality commonly used in assessment of cardiomyopathy. We aimed to identify specific CMR features associated with MA-CMP. A retrospective cohort study of CMR scans was performed in a single centre between January 2015 and December 2020. Thirty patients with MA-CMP who had undergone CMR were identified. MA-CMP was defined as those with a history of significant methamphetamine use hospitalised with acute decompensated heart failure (other causes of cardiomyopathy excluded). A retrospective analysis of index admission CMRs was performed. All studies were performed on a 1.5 T CMR scanner. The mean age of MA-CMP patients was 43.7 ± 7.5 years, and 86.7

Background: Low cardiorespiratory fitness (CRF) and obesity are related to the development and maintenance of atrial fibrillation (AF). The aim of this study was to determine the association between CRF, obesity and left atrial (LA) mechanical parameters in patients with AF. Methods: A cohort of 154 consecutive paroxysmal and persistent AF patients (Age: 62 +/- 10, 26% female) referred for exercise stress testing and transthoracic echocardiography were included. We included patients in sinus rhythm with preserved left ventricular ejection fraction who were able to complete a maximal exercise test. Left atrial strain in the reservoir (LASr), booster (LASb) and conduit (LASc) phases were assessed using dedicated software. LA stiffness, emptying fraction (LAEF) and LA to LV ratio were calculated using previously described formulas. Results: CRF was positively associated with LAEF (8 = 1.3, 95% CI 0.1-2.3, p = 0.02), reservoir (8 = 1.5, 95% CI 0.9-2.1, p < 0.001), booster (8 = 0.8, 95% CI 0.4-1.2, p < 0.001) and conduit strain (8 = 0.7, 95% CI 0.3-1.1, p = 0.001). We observed an inverse association between CRF and both LA stiffness index (8 =-0.02, 95% CI (- 0.03)-(-0.01), p < 0.001) and LA to LV ratio (8 =-0.03, 95% CI (- 0.04)-(-0.01), p < 0.001). Obese patients had significantly higher indexed LA volumes compared to overweight and normal BMI patients. The association between obesity and measures of LA function and stiffness did not reach statistical significance. Conclusion: Among AF patients, higher CRF was independently associated with greater LA function and compliance. Obesity was associated with higher LA volumes yet preserved mechanical function.

Although cardiac resynchronization therapy (CRT) is an established therapy in selected patients with heart failure with reduced ejection fraction (HFrEF), its role in orthotopic heart transplant (OHT) recipients remains understudied. We describe a case of successful CRT implantation in an OHT recipient for HFrEF and high-grade atrioventricular block. This case highlights the deliberations made given the lack of clinical trial and observational evidence for this therapy in OHT recipients. Learning Objective:This case demonstrates the feasibility of cardiac resynchronization therapy (CRT) in an orthotopic heart transplant (OHT) recipient and adds to the scarcely reported data on the utility of CRT in this population. Given the exclusion of OHT recipients from the major CRT trials, further research is required to refine the indications for CRT implantation in this population.

Myopericarditis is a rare side effect following messenger ribonucleic acid (mRNA) COVID-19 vaccination. Cardiac magnetic resonance (CMR) imaging can detect myopericarditis with high sensitivity and resolution of CMR abnormalities mirrors clinical improvement.

The growth in methamphetamine usage worldwide continues to present increasing societal and health care challenges. With the escalation of its usage in a variety of social demographics, the entity of methamphetamine-associated cardiomyopathy (MA-CMP) has emerged. This entity is increasingly responsible for an important proportion of heart failure burden in both admissions to hospital and in those individuals requiring chronic heart failure care. MA-CMP poses some unique challenges including its recognition, particularly in younger patients presenting with new-onset heart failure, its severity at presentation and complications as well as management options. The challenging nature of methamphetamine addiction and the necessity to achieve abstinence is a fundamental aspect of management of this condition. As methamphetamine use continues at high levels in Australia, the burden of MA-CMP will inevitably increase and, therefore, all clinicians responsible for heart failure management require an awareness of this disease entity and the specific clinical challenges of its care.

Cardiac magnetic resonance (CMR) imaging is the gold standard imaging for cardiac function and myocardial tissue characterisation. Diagnostic image quality can be affected by susceptibility artefacts related to ferromagnetic components in implantable cardiac devices. We assessed CMR diagnostic image quality in patients with implantable MR-conditional pacemakers and defibrillators.

Introduction Atrial fibrillation (AF) is associated with significantly impaired quality-of-life. Iron deficiency (ID) is prevalent in patients with AF. Correction of ID in other patient populations with intravenous iron supplementation has been shown to be a safe, convenient and effective way of improving exercise tolerance, fatigue and quality-of-life. The IRON-AF (Effect of Iron Repletion in Atrial Fibrillation) study is designed to assess the effect of iron repletion with intravenous ferric carboxymaltose in patients with AF and ID.Methods and analysis The IRON-AF study is a double-blind, randomised controlled trial that will recruit at least 84 patients with AF and ID. Patients will be randomised to receive infusions of either ferric carboxymaltose or placebo, given in repletion and then maintenance doses. The study will have follow-up visits at weeks 4, 8 and 12. The primary endpoint is change in peak oxygen uptake from baseline to week 12, as measured by cardiopulmonary exercise testing (CPET) on a cycle ergometer. Secondary endpoints include changes in quality-of-life and AF disease burden scores, blood parameters, other CPET parameters, transthoracic echocardiogram parameters, 6-minute walk test distance, 7-day Holter/Event monitor burden of AF, health resource utilisation and mortality.Ethics and dissemination The study protocol has been approved by the Central Adelaide Local Health Network Human Research Ethics Committee, Australia. The results of this study will be disseminated through publications in peer-reviewed journals and conference presentations.Trial registration number Australian New Zealand Clinical Trials Registry (ACTRN12620000285954).

Heart transplantation remains the only curative therapy for end-stage heart failure, offering excellent 5-year survival rates of up to 72% for patients with otherwise extremely bleak prognostic outlooks.1Lund L.H. Edwards L.B. Kucheryavaya A.Y. et al.The registry of the International Society for Heart and Lung Transplantation: thirty-first official adult heart transplant report--2014; focus theme: retransplantation.J Heart Lung Transplant. 2014; 33: 996-1008Abstract Full Text Full Text PDF PubMed Scopus (388) Google Scholar However, a significant challenge for heart transplant candidates is surviving the pretransplant waitlist time, which can be considerable owing to donor organ availability. Reassuringly, waitlist survival rates have improved dramatically in recent years, with 1-year survival on the waitlist increasing from 34.1% in 1987–1990 to 67.8% in 2011–2017.2Bakhtiyar S.S. Godfrey E.L. Ahmed S. et al.Survival on the heart transplant waiting list.JAMA Cardiol. 2020; 5: 1227Crossref PubMed Scopus (11) Google Scholar Factors influencing these improved waitlist survival rates include improvements in patient selection, development and utility of prognostic pharmacological therapies in heart failure, and increased implementation of mechanical circulatory support such as left ventricular assist devices (LVAD) as a bridge to cardiac transplantation. In this issue of Heart Rhythm O2, Lin and colleagues3Lin A.Y. Duran J.M. Sykes A. et al.Association between implantable cardioverter-defibrillator and survival in patients awaiting heart transplantation: a meta-analysis and systematic review.Heart Rhythm O2. 2021; 2: 710-718Google Scholar evaluated the potential value of implantable cardioverter-defibrillator (ICD) therapy in improving waitlist survival rates in those with end-stage heart failure who may not fulfil the standard guideline criteria for ICD implantation. This analysis identified 10 studies comparing outcomes in 36,112 heart transplant candidates with and without ICDs between 1992 and 2014, thereby covering a period over which heart failure management (both pharmacological and nonpharmacological) has evolved considerably. Despite the cohort in this meta-analysis representing a symptomatic advanced heart failure population, only 62.5% of these patients had an ICD. The outcomes assessed included total mortality, sudden cardiac death, non–sudden cardiac death, and survival to heart transplantation. Using a random-effects model for calculating unadjusted pooled risk ratios, the authors showed that ICDs conferred a statistically significant 40% reduction in total mortality, 73% reduction in sudden cardiac death, and 9% increased chance of surviving to heart transplantation. An adjusted analysis confirmed a significant reduction in total mortality with ICDs. On the other hand, non–sudden cardiac death was not significantly reduced by the presence of an ICD. Further subanalyses showed that there was no difference in total mortality when comparing primary prevention ICDs with secondary prevention ICDs, while the proportion of patients receiving inappropriate ICD therapies was low, at 5%–7%, and those receiving appropriate ICD therapies was 26% (15%–65%). The authors of this study are to be commended for highlighting an important issue with respect to the management of patients with end-stage heart failure listed for heart transplantation. The finding that ICDs were associated with reduced all-cause mortality rates and increased heart transplantation rates, driven largely by a dramatic reduction in sudden cardiac death, suggests an ongoing incidence of life-threatening ventricular arrhythmias in this cohort of patients. Current guidelines do not recommend ICDs for most NYHA class IV heart failure patients, as the risks of cardiac decompensation and pump failure outweigh those of sudden cardiac death.4Epstein A.E. DiMarco J.P. Ellenbogen K.A. et al.2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2013; 61: e6-e75PubMed Google Scholar,5Priori S.G. Blomström-Lundqvist C. Mazzanti A. et al.2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC).Eur Heart J. 2015; 36: 2793-2867Crossref PubMed Scopus (2144) Google Scholar However, heart transplant candidates represent a unique cohort of NYHA class IV heart failure patients in whom every effort is made to reduce the risk of pump failure through use of inotropic support and mechanical circulatory devices. With this reduced impact of pump failure, the risk of sudden cardiac death assumes greater relevance, and Lin and colleagues highlighted this by reporting that the number of patients reaching transplant can be improved through negating the effect of sudden cardiac death. Furthermore, many new-generation ICDs now exhibit novel algorithms for the remote detection of pulmonary congestion indicative of impending cardiac decompensation to facilitate early identification of cardiac decompensation and intervention to reduce hospitalization.6Mohebali D. Kittleson M.M. Remote monitoring in heart failure: current and emerging technologies in the context of the pandemic.Heart. 2021; 107: 366-372Crossref PubMed Scopus (7) Google Scholar Such technological advancement may add additional benefits of ICDs in heart transplant candidates beyond sudden cardiac death reduction. Although the paper presents compelling data, several limitations should be considered. The populations studied are likely not representative of a contemporary heart transplant population, as the majority of studies included patients enrolled more than 10 years ago. Patients listed for heart transplant in the current era are likely to be older and have more severe heart failure.5Priori S.G. Blomström-Lundqvist C. Mazzanti A. et al.2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC).Eur Heart J. 2015; 36: 2793-2867Crossref PubMed Scopus (2144) Google Scholar Additionally, heart transplant candidates today are significantly more likely to be bridged to transplant with mechanical circulatory support. While the proportion of patients with LVADs in this study was 27%, the overall prevalence of LVADs in patients listed for heart transplant in 2018 in the United States was 43.6%.7Colvin M. Smith J.M. Hadley N. et al.OPTN/SRTR 2018 annual data report: heart.Am J Transplant. 2020; 20: 340-426Crossref PubMed Scopus (78) Google Scholar Notably, overall survival to transplant for patients with LVADs has increased, from 10% in 1996–2000 to 70% in 2011–2017.2Bakhtiyar S.S. Godfrey E.L. Ahmed S. et al.Survival on the heart transplant waiting list.JAMA Cardiol. 2020; 5: 1227Crossref PubMed Scopus (11) Google Scholar One of the most important developments in LVAD technology is the change from pulsatile to continuous-flow LVADs, which have been shown to be associated with better survival and are now more commonly used.8Cheng A. Williamitis C.A. Slaughter M.S. Comparison of continuous-flow and pulsatile-flow left ventricular assist devices: is there an advantage to pulsatility?.Ann Cardiothorac Surg. 2014; 3: 573-581PubMed Google Scholar While recent evidence suggests that ICD use is associated with reduced mortality in patients with LVADs, this benefit has not extended to studies of patients with continuous-flow LVADs.9Vakil K. Kazmirczak F. Sathnur N. et al.Implantable cardioverter-defibrillator use in patients with left ventricular assist devices: a systematic review and meta-analysis.JACC Heart Fail. 2016; 4: 772-779Crossref PubMed Scopus (56) Google Scholar Therefore, whether the results of this study can be extended to contemporary heart transplant candidates remains unclear. Additionally, the results of this analysis may be confounded by selection bias, as most of the included patients (99%) had ICDs implanted prior to heart transplant listing, leaving minimal evidence to support the implantation of ICDs in patients already listed for heart transplant. Notwithstanding the findings of this study, several additional challenges may continue to limit the use of ICDs in heart transplant candidates. First, primary prevention ICDs are recommended for patients with heart failure and no improvement in ejection fraction after at least 3 months of optimal medical therapy.4Epstein A.E. DiMarco J.P. Ellenbogen K.A. et al.2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2013; 61: e6-e75PubMed Google Scholar,5Priori S.G. Blomström-Lundqvist C. Mazzanti A. et al.2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC).Eur Heart J. 2015; 36: 2793-2867Crossref PubMed Scopus (2144) Google Scholar The feasibility of such a delay in ICD implant may be limited in a select group of patients listed for heart transplant who develop severe acute heart failure. Yet, implantation of ICD in these patients would sit outside of current clinical guidelines and remain unsupported by clinical evidence. Second, the choice of ICD types require careful consideration given reports of significant electromagnetic interactions between subcutaneous ICDs and LVADs, including increased risk of undersensing and inappropriate shocks.10Ishida Y. Payne J.E. Field M.E. Gold M.R. Electromagnetic interference from left ventricular assist devices in patients with subcutaneous implantable cardioverter-defibrillators.J Cardiovasc Electrophysiol. 2020; 31: 1195-1201Crossref PubMed Scopus (8) Google Scholar Last, there is increasing recognition of the issue of retained fragments of ICD leads following transplant, with a single-center cohort study reporting a not insignificant incidence of 27%, implicating future risk of upper extremity deep vein thrombosis and preventing the use of magnetic resonance imaging.11Holzhauser L. Imamura T. Nayak H.M. et al.Consequences of retained defibrillator and pacemaker leads after heart transplantation—an underrecognized problem.J Card Fail. 2018; 24: 101-108Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar This study serves as an important reminder to both heart failure and electrophysiology physicians regarding the clinical significance of sudden cardiac death and survival in those who are candidates for heart transplant. A prospective evaluation of this issue will remain a challenge owing to the ethics of withholding ICD implantation in a sick population with poor reserve to survive a sudden cardiac death event. Taken together, while this meta-analysis of ICDs in heart transplant candidates purports a significant role of ICDs in reinforcing the bridge to transplant by increasing survival to cardiac transplantation and reducing sudden cardiac death, clinical equipoise, multidisciplinary input, and shared decision-making remain essential when considering ICD implantation for this select cohort of heart failure patients. Dr Ariyaratnam is supported by a postgraduate scholarship from the University of Adelaide . Dr Lau is supported by a Mid-Career Fellowship from The Hospital Research Foundation .

Background:The long-term effects of arteriovenous fistula (AVF) ligation on cardiovascular structure following kidney transplantation remain uncertain. A prospective randomized, controlled trial (RCT) examined the effect of AVF ligation at 6 months on cardiovascular magnetic resonance imaging (CMR)-derived parameters in 27 kidney transplant recipients compared with 27 controls. A mean decrease in left ventricular mass (LVM) of 22.1 g (95% CI, 15.0 to 29.1) was observed compared with an increase of 1.2 g (95% CI, -4.8 to 7.2) in the control group (P<0.001). We conducted a long-term follow-up observational cohort study in the treated cohort to determine the evolution of CMR-derived parameters compared with those documented at 6 months post-AVF ligation. Methods:We performed CMR at long-term follow-up in the AVF ligation observational cohort from our original RCT published in 2019. Results were compared with CMR at 6 months postintervention. The coprimary end point was the change in CMR-derived LVM and LVM index at long-term follow-up from imaging at 6 months postindex procedure. Results:At a median of 5.1 years (interquartile range, 4.7-5.5 years), 17 patients in the AVF ligation group were studied with repeat CMR with a median duration to follow-up imaging of 5.1 years (IQR, 4.7-5.5 years). Statistically significant further reductions in LVM (-17.6±23.0 g, P=0.006) and LVM index (-10.0±13.0 g/m2, P=0.006) were documented. Conclusions:The benefit of AVF ligation on LVM and LVM index regression appears to persist long term. This has the potential to lead to a significant reduction in cardiovascular mortality.

In pulmonary arterial hypertension (PAH), progressive right ventricular (RV) dysfunction is believed to be largely secondary to RV ischaemia. A recent pilot study has demonstrated the feasibility of Oxygen-sensitive (OS) cardiovascular magnetic resonance (CMR) to detect in-vivo RV myocardial oxygenation. The aims of the present study therefore, were to assess the prevalence of RV myocardial ischaemia and relationship with RV myocardial interstitial changes in PAH patients with non-obstructive coronaries, and corelate with functional and haemodynamic parameters. We prospectively recruited 42 patients with right heart catheter (RHC) proven PAH and 11 healthy age matched controls. The CMR examination involved standard functional imaging, OS-CMR imaging and native T1 mapping. An ΔOS-CMR signal intensity (SI) index (stress/rest signal intensity) was acquired at RV anterior, RV free-wall and RV inferior segments. T1 maps were acquired using Shortened Modified Look-Locker Inversion recovery (ShMOLLI) at the inferior RV segment. The inferior RV ΔOS-CMR SI index was significantly lower in PAH patients compared with healthy controls (9.5 (– 7.4–42.8) vs 12.5 (9–24.6)%, p = 0.02). The inferior RV ΔOS-CMR SI had a significant correlation to RV inferior wall thickness (r = – 0.7, p < 0.001) and RHC mean pulmonary artery pressure (mPAP) (r = – 0.4, p = 0.02). Compared to healthy controls, patients with PAH had higher native T1 in the inferior RV wall: 1303 (1107–1612) vs 1232 (1159–1288)ms, p = 0.049. In addition, there was a significant difference in the inferior RV T1 values between the idiopathic PAH and systemic sclerosis associated PAH patients: 1242 (1107–1612) vs 1386 (1219–1552)ms, p = 0.007. Blunted OS-CMR SI suggests the presence of in-vivo microvascular RV dysfunction in PAH patients. The native T1 in the inferior RV segments is significantly increased in the PAH patients, particularly among the systemic sclerosis associated PAH group.