Impaired left-ventricular global longitudinal strain by feature-tracking cardiac MRI predicts mortality in systemic sclerosis.

Impaired left-ventricular (LV) and right-ventricular (RV) cardiac magnetic resonance (CMR) strain has been documented in systemic sclerosis (SSc). However, it is unknown whether the CMR strain is predictive of adverse outcomes in SSc. Therefore, we set out to investigate the prognostic value of CMR strain in SSc. Patients with SSc who underwent CMR for clinical indications between 11/2010 and 07/2020 were retrospectively studied. LV and RV strain was evaluated by feature tracking. The association between strain, late gadolinium enhancement (LGE), and survival was evaluated with time to event and Cox-regression analyses. During the study period, 42 patients with SSc (age: 57 ± 14 years, 83% female, 57% limited cutaneous SSc, SSc duration: 7 ± 8 years) underwent CMR. During the median follow-up of 3.6 years, 11 patients died (26%). Compared to surviving patients, patients who died had significantly worse LV GLS (- 8.2 ± 6.2% versus - 12.1 ± 2.9%, p = 0.03), but no difference in LV global radial, circumferential, or RV strain values. Patients within the quartile of most impaired LV GLS (≥ - 12.8%, n = 10) had worse survival when compared to patients with preserved LV GLS (< - 12.8%, n = 32, log-rank p = 0.02), which persisted after controlling for LV cardiac output, LV cardiac index, reduced LV ejection fraction, or presence of LGE. In addition, patients who had both impaired LV GLS and LGE (n = 5) had worse survival than patients with LGE or impaired GLS alone (n = 14) and compared to those without any of these features (n = 17, p = 0.003). In our retrospective cohort of patients with SSc undergoing CMR for clinical indications, LV GLS and LGE were found to be predictive of overall survival.

Cardiovascular magnetic resonance in women with cardiovascular disease: position statement from the Society for Cardiovascular Magnetic Resonance (SCMR).

This document is a position statement from the Society for Cardiovascular Magnetic Resonance (SCMR) on recommendations for clinical utilization of cardiovascular magnetic resonance (CMR) in women with cardiovascular disease. The document was prepared by the SCMR Consensus Group on CMR Imaging for Female Patients with Cardiovascular Disease and endorsed by the SCMR Publications Committee and SCMR Executive Committee. The goals of this document are to (1) guide the informed selection of cardiovascular imaging methods, (2) inform clinical decision-making, (3) educate stakeholders on the advantages of CMR in specific clinical scenarios, and (4) empower patients with clinical evidence to participate in their clinical care. The statements of clinical utility presented in the current document pertain to the following clinical scenarios: acute coronary syndrome, stable ischemic heart disease, peripartum cardiomyopathy, cancer therapy-related cardiac dysfunction, aortic syndrome and congenital heart disease in pregnancy, bicuspid aortic valve and aortopathies, systemic rheumatic diseases and collagen vascular disorders, and cardiomyopathy-causing mutations. The authors cite published evidence when available and provide expert consensus otherwise. Most of the evidence available pertains to translational studies involving subjects of both sexes. However, the authors have prioritized review of data obtained from female patients, and direct comparison of CMR between women and men. This position statement does not consider CMR accessibility or availability of local expertise, but instead highlights the optimal utilization of CMR in women with known or suspected cardiovascular disease. Finally, the ultimate goal of this position statement is to improve the health of female patients with cardiovascular disease by providing specific recommendations on the use of CMR.

Opportunities for improved cardiovascular disease prevention in oncology patients.

PURPOSE OF REVIEW: Cancer patients often have cardiovascular risk factors at the time of cancer diagnosis, which are known to increase the risk of cardiotoxicity. Cancer survivors have significantly higher cardiovascular risk. Current cardiovascular disease prevention guidelines are based on studies that largely excluded these patients. We reviewed recent data regarding cardiovascular disease prevention in this population. RECENT FINDINGS: Nonpharmacologic therapies aiming to reduce 'lifestyle toxicity' produced by cancer treatments have demonstrated potential to decrease the incidence of adverse outcomes. Exercise before, during and after cancer treatment not only promotes higher quality of life and cardiorespiratory fitness but also reduces adverse cardiovascular outcomes. Lipid and cardiometabolic disease management is paramount but predominantly based on data that excludes these populations of cancer patients and survivors. SUMMARY: A comprehensive approach including medical evaluation, prescriptive exercise, cardiac risk factor modification, education, counseling, pharmacologic and behavioral interventions are needed in cancer patients. These interventions constitute the core of cardio-oncology rehabilitation programs, which if implemented appropriately may help reduce cardiovascular events in this population. Knowledge gaps in these areas are starting to be addressed by ongoing clinical trials.

Valvular imaging in the era of feature-tracking: A slice-following cardiac MR sequence to measure mitral flow.

BACKGROUND: In mitral valve dysfunction, noninvasive measurement of transmitral blood flow is an important clinical examination. Flow imaging of the mitral valve, however, is challenging, since it moves in and out of the image plane during the cardiac cycle. PURPOSE: To more accurately measure mitral flow, a slice-following MRI phase contrast sequence is proposed. This study aimed to implement such a sequence, validate its slice-following functionality in a phantom and healthy subjects, and test its feasibility in patients with mitral valve dysfunction. STUDY TYPE: Prospective. PHANTOM AND SUBJECTS: The slice-following functionality was validated in a cone-shaped phantom by measuring the depicted slice radius. Sixteen healthy subjects and 10 mitral valve dysfunction patients were enrolled at two sites. FIELD STRENGTH/SEQUENCE: 1.5T and 3T gradient echo cine phase contrast. ASSESSMENT: A single breath-hold retrospectively gated sequence using offline feature-tracking of the mitral valve was developed. Valve displacements were measured and imported to the scanner, allowing the slice position to change dynamically based on the cardiac phase. Mitral valve imaging was performed with slice-following and static imaging planes. Validation was performed by comparing mitral stroke volume with planimetric and aortic stroke volume. STATISTICAL TESTS: Measurements were compared using linear regression, Pearson's R, parametric paired t-tests, Bland-Altman analysis, and intraclass correlation coefficient (ICC). RESULTS: Phantom experiments confirmed accurate slice displacements. Slice-following was feasible in all subjects, yielding physiologically accurate mitral flow patterns. In healthy subjects, mitral and aortic stroke volumes agreed, with ICC = 0.72 and 0.90 for static and slice-following planes; with bias ±1 SDs 23.2 ± 13.2 mls and 8.4 ± 10.8 mls, respectively. Agreement with planimetry was stronger, with ICC = 0.84 and 0.96; bias ±1 SDs 13.7 ± 13.7 mls and -2.0 ± 8.8 mls for static and slice-following planes, respectively. DATA CONCLUSION: Slice-following outperformed the conventional sequence and improved the accuracy of transmitral flow, which is important for assessment of diastolic function and mitral regurgitation. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:1412-1421.

Cardiovascular disease in women: insights from magnetic resonance imaging.

The presentation and identification of cardiovascular disease in women pose unique diagnostic challenges compared to men, and underrecognized conditions in this patient population may lead to clinical mismanagement.This article reviews the sex differences in cardiovascular disease, explores the diagnostic and prognostic role of cardiovascular magnetic resonance (CMR) in the spectrum of cardiovascular disorders in women, and proposes the added value of CMR compared to other imaging modalities. In addition, this article specifically reviews the role of CMR in cardiovascular diseases occurring more frequently or exclusively in female patients, including Takotsubo cardiomyopathy, connective tissue disorders, primary pulmonary arterial hypertension and peripartum cardiomyopathy. Gaps in knowledge and opportunities for further investigation of sex-specific cardiovascular differences by CMR are also highlighted.

Nuclear cardiology in the context of multimodality imaging to detect cardiac toxicity from cancer therapeutics: Established and emerging methods.

The complexity of cancer therapies has vastly expanded in the last decade, along with type and severity of cardiac toxicities associated with these treatments. Prevention of pre-clinical cardiotoxicity may improve cardiovascular outcomes and circumvent the decision to place life-sustaining chemotherapeutic agents on hold, making the early detection of cancer therapeutic related cardiac toxicity with non-invasive imaging essential to the care of these patients. There are several established methods of cardiac imaging in the areas of nuclear cardiology, echocardiography, computed tomography, and cardiac magnetic resonance imaging that are used to assess for cardiovascular toxicity of cancer treatments, with several methods under development. The following review will provide an overview of current and emerging imaging techniques in these areas.

REPAIRit: Improving Myocardial Nulling and Ghosting Artifacts of 3D Navigator-Gated Late Gadolinium Enhancement Imaging During Arrhythmia.

BACKGROUND: Cardiac 3D navigator-gated late gadolinium enhancement (LGE) imaging is important for assessment of left atrial fibrosis, but the image quality is often degraded due to arrhythmia. PURPOSE: To investigate a novel 3D LGE sequence with improved myocardial nulling and reduced ghosting artifacts during arrhythmia. STUDY TYPE: Prospective. POPULATION: Arrhythmia patients (n = 14). SEQUENCE: The proposed technique, REPAIRit (Regrowth Equalization Pulse for Arrhythmias in Inversion Recovery with automatic inversion time calculation), inserts a saturation pulse with a dynamic flip angle into the 3D LGE sequence to minimize arrhythmia-induced signal fluctuations. Using ShMOLLI (shortened modified Look-Locker imaging) to estimate myocardial T1 , REPAIRit automatically calculates the optimal inversion time (TI) based on Bloch equations. ASSESSMENT: REPAIRit LGE and the standard LGE were compared with simulations, phantom imaging, and patient studies. Patient images were assessed quantitatively, based on ghost-to-noise ratio (GNR), blood signal-to-noise ratio (SNRb), myocardial signal-to-noise ratio (SNRm), and blood-to-myocardium contrast-to-noise ratio (CNR), and qualitatively on a 4-point scale. Patients were subgrouped based on the presence of arrhythmia to assess the image quality difference. STATISTICAL TESTS: The two LGE sequences were compared by Student's t-test and Wilcoxon signed-rank test. The two patient-subgroups were compared using Welch's t-test and Wilcoxon rank-sum test. RESULTS: In 14 analyzed patients, REPAIRit LGE significantly lowered GNR (1.25 ± 0.41 vs. 1.42 ± 0.42, P = 0.04), reduced SNRm (1.90 ± 0.60 vs. 3.16 ± 1.66, P = 0.01), improved ghosting artifact scores (2.5 ± 0.6 vs. 2.2 ± 0.9, P = 0.03), myocardial nulling scores (2.7 ± 0.5 vs. 2.3 ± 0.7, P = 0.02), and atrial quality scores (2.8 ± 0.3 vs. 2.4 ± 0.8, P = 0.03) compared with the standard LGE. Comparing patients with arrhythmia (n = 6) to those without (n = 8) during the scan, the former had lower left ventricular (LV) myocardial T1 s (430 ± 26 msec vs. 469 ± 39 msec, P = 0.06) but similar blood T1 s (318 ± 55 msec vs. 316 ± 27 msec, P = 0.96), and significantly lower blood SNR (5.2 ± 1.8 vs. 9.2 ± 3.0, P = 0.01) and significantly worse image quality (P = 0.01 for REPAIRit and P = 0.03 for standard). DATA CONCLUSION: REPAIRit improves myocardial nulling and reduces ghosting artifacts of 3D LGE under arrhythmia. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2019;49:688-699.

Prognostic and functional implications of left atrial late gadolinium enhancement cardiovascular magnetic resonance.

BACKGROUND: Left atrial (LA) late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging is indicative of fibrosis, and has been correlated with reduced LA function, increased LA volume, and poor procedural outcomes in cohorts with atrial fibrillation (AF). However, the role of LGE as a prognostic biomarker for arrhythmia in cardiac disease has not been examined. METHODS: In this study, we assessed LA LGE using a 3D LGE CMR sequence to examine its relationships with new onset atrial arrhythmia, and LA and left ventricular (LV) mechanical function. RESULTS: LA LGE images were acquired in 111 patients undergoing CMR imaging, including 66 patients with no prior history of an atrial arrhythmia. During the median follow-up of 2.7 years (interquartile range (IQR) 1.8-3.7 years), 15/66 (23%) of patients developed a new atrial arrhythmia. LA LGE ≥10% of LA myocardial volume was significantly associated with an increased rate of new-onset atrial arrhythmia, with a hazard ratio of 3.16 (95% CI 1.14-8.72), p = 0.026. There were significant relationships between LA LGE and both LA ejection fraction (r = - 0.39, p < 0.0005) and echocardiographic LV septal e' (r = - 0.24, p = 0.04) and septal E/e' (r = 0.31, p = 0.007). CONCLUSIONS: Elevated LA LGE is associated with reduced LA function and reduced LV diastolic function. LA LGE is associated with new onset atrial arrhythmia during follow-up.

Reverse double inversion-recovery: Improving motion robustness of cardiac T2 -weighted dark-blood turbo spin-echo sequence.

BACKGROUND: Cardiac dark-blood turbo spin-echo (TSE) imaging is sensitive to through-plane motion, resulting in myocardial signal reduction. PURPOSE: To propose and validate reverse double inversion-recovery (RDIR)-a dark-blood preparation with improved motion robustness for the cardiac dark-blood TSE sequence. STUDY TYPE: Prospective. POPULATION: Healthy volunteers (n = 10) and patients (n = 20). FIELD STRENGTH: 1.5T (healthy volunteers) and 3T (patients). ASSESSMENT: Compared to double inversion recovery (DIR), RDIR swaps the two inversion pulses in time and places the slice-selective 180° in late-diastole of the previous cardiac cycle to minimize slice misregistration. RDIR and DIR were performed in the same left-ventricular basal short-axis slice. Healthy subjects were imaged with two preparation slice thicknesses, 110% and 200%, while patients were imaged using a 200% slice thickness only. Images were assessed quantitatively, by measuring the myocardial signal heterogeneity and the extent of dropout, and also qualitatively on a 5-point scale. STATISTICAL TESTS: Quantitative and qualitative data were assessed with Student's t-test and Wilcoxon signed-rank test, respectively. RESULTS: In healthy subjects, RDIR with 110% slice thickness significantly reduced signal heterogeneity in both the left ventricle (LV) and right ventricle (RV) (LV: P = 0.006, RV: P < 0.0001) and the extent of RV dropout (P < 0.0001), while RDIR with 200% slice thickness significantly reduced RV signal heterogeneity (P = 0.001) and the extent of RV dropout (P = 0.0002). In patients, RDIR significantly reduced RV myocardial signal heterogeneity (0.31 vs. 0.43; P = 0.003) and the extent of RV dropout (24% vs. 46%; P = 0.0005). LV signal heterogeneity exhibited a trend towards improvement with RDIR (0.12 vs. 0.16; P = 0.06). Qualitative evaluation showed a significant improvement of LV and RV visualization in RDIR compared to DIR (LV: P = 0.04, RV: P = 0.0007) and a significantly improved overall image quality (P = 0.03). DATA CONCLUSION: RDIR TSE is less sensitive to through-plane motion, potentiating increased clinical utility for black-blood TSE. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:1498-1508.

Atrial fibrosis by cardiac MRI is a correlate for atrial stiffness in patients with atrial fibrillation.

A relationship between left atrial strain and pressure has been demonstrated in many studies, but not in an atrial fibrillation (AF) cohort. In this work, we hypothesized that elevated left atrial (LA) tissue fibrosis might mediate and confound the LA strain vs. pressure relationship, resulting instead in a relationship between LA fibrosis and stiffness index (mean LA pressure/LA reservoir strain). Sixty-seven patients with AF underwent a standard cardiac MR exam including long-axis cine views (2 and 4-ch) and a free-breathing high resolution three-dimensional late gadolinium enhancement (LGE) of the atrium (N = 41), within 30 days prior to AF ablation, at which procedure invasive mean left atrial pressure (LAP) was measured. LV and LA Volumes, EF, and comprehensive analysis of LA strains (strain and strain rates and strain timings during the atrial reservoir, conduit and active, i.e. active atrial contraction, phases) were measured and LA fibrosis content (LGE (ml)) was assessed from 3D LGE volumes. LA LGE was well correlated to atrial stiffness index overall (R = 0.59, p < 0.001), and among patient subgroups. Pressure was only correlated to maximal LA volume (R = 0.32) and the time to peak reservoir strain rate (R = 0.32) (both p < 0.01), among all functional measurements. LA reservoir strain was strongly correlated with LAEF (R = 0.95, p < 0.001) and LA minimum volume (r = 0.82, p < 0.001). In our AF cohort, pressure is correlated to maximum LA volume and time to peak reservoir strain. LA pressure/ LA reservoir strain, a metric of stiffness, correlates with LA fibrosis (LA LGE), reflecting Hook's Law.

Artificial intelligence-enhanced risk stratification of cancer therapeutics-related cardiac dysfunction using electrocardiographic images.

Background: Risk stratification strategies for cancer therapeutics-related cardiac dysfunction (CTRCD) rely on serial monitoring by specialized imaging, limiting their scalability. Objectives: To examine an artificial intelligence (AI)-enhanced electrocardiographic (AI-ECG) surrogate for imaging risk biomarkers, and its association with CTRCD. Methods: Across a five-hospital U.S.-based health system (2013-2023), we identified patients with breast cancer or non-Hodgkin lymphoma (NHL) who received anthracyclines (AC) and/or trastuzumab (TZM), and a control cohort receiving immune checkpoint inhibitors (ICI). We deployed a validated AI model of left ventricular systolic dysfunction (LVSD) to ECG images (≥0.1, positive screen) and explored its association with i) global longitudinal strain (GLS) measured within 15 days (n=7,271 pairs); ii) future CTRCD (new cardiomyopathy, heart failure, or left ventricular ejection fraction [LVEF]<50%), and LVEF<40%. In the ICI cohort we correlated baseline AI-ECG-LVSD predictions with downstream myocarditis. Results: Higher AI-ECG LVSD predictions were associated with worse GLS (-18% [IQR:-20 to -17%] for predictions<0.1, to -12% [IQR:-15 to -9%] for ≥0.5 (p<0.001)). In 1,308 patients receiving AC/TZM (age 59 [IQR:49-67] years, 999 [76.4%] women, 80 [IQR:42-115] follow-up months) a positive baseline AI-ECG LVSD screen was associated with ~2-fold and ~4.8-fold increase in the incidence of the composite CTRCD endpoint (adj.HR 2.22 [95%CI:1.63-3.02]), and LVEF<40% (adj.HR 4.76 [95%CI:2.62-8.66]), respectively. Among 2,056 patients receiving ICI (age 65 [IQR:57-73] years, 913 [44.4%] women, follow-up 63 [IQR:28-99] months) AI-ECG predictions were not associated with ICI myocarditis (adj.HR 1.36 [95%CI:0.47-3.93]). Conclusion: AI applied to baseline ECG images can stratify the risk of CTRCD associated with anthracycline or trastuzumab exposure.

Multimodality Cardiac Imaging and the Imaging Workforce in the United States: Diversity, Disparities, and Future Directions.

Innovations in cardiac imaging have fundamentally advanced the understanding and treatment of cardiovascular disease. These advances in noninvasive cardiac imaging have also expanded the role of the cardiac imager and dramatically increased the demand for imagers who are cross-trained in multiple modalities. However, we hypothesize that there is significant variation in the availability of cardiac imaging expertise and a disparity in the adoption of advanced imaging technologies across the United States. To evaluate this, we have brought together the leaders of cardiovascular imaging societies, imaging trainees, as well as collaborated with national imaging accreditation commissions and imaging certification boards to assess the state of cardiac imaging and the diversity of the imaging workforce in the United States. Aggregate data confirm the presence of critical gaps, such as limited access to imaging and imaging expertise in rural communities, as well as disparities in the imaging workforce, notably among women and underrepresented minorities. Based on these results, we have proposed solutions to promote and maintain a robust and diverse community of cardiac imagers and improve equity and accessibility for cardiac imaging technologies.

Predictors and Risk Score for Immune Checkpoint-Inhibitor-Associated Myocarditis Severity.

Background: Immune-checkpoint inhibitors (ICI) are associated with life-threatening myocarditis but milder presentations are increasingly recognized. The same autoimmune process that causes ICI-myocarditis can manifest concurrent generalized myositis, myasthenia-like syndrome, and respiratory muscle failure. Prognostic factors for this "cardiomyotoxicity" are lacking. Methods: A multicenter registry collected data retrospectively from 17 countries between 2014-2023. A multivariable cox regression model (hazard-ratio(HR), [95%confidence-interval]) was used to determine risk factors for the primary composite outcome: severe arrhythmia, heart failure, respiratory muscle failure, and/or cardiomyotoxicity-related death. Covariates included demographics, comorbidities, cardio-muscular symptoms, diagnostics, and treatments. Time-dependent covariates were used and missing data were imputed. A point-based prognostic risk score was derived and externally validated. Results: In 748 patients (67% male, age 23-94), 30-days incidence of the primary composite outcome, cardiomyotoxic death, and overall death were 33%, 13%, and 17% respectively. By multivariable analysis, the primary composite outcome was associated with active thymoma (HR=3.60[1.93-6.72]), presence of cardio-muscular symptoms (HR=2.60 [1.58-4.28]), low QRS-voltage on presenting electrocardiogram (HR for ≤0.5mV versus >1mV=2.08[1.31-3.30]), left ventricular ejection fraction (LVEF) <50% (HR=1.78[1.22-2.60]), and incremental troponin elevation (HR=1.86 [1.44-2.39], 2.99[1.91-4.65], 4.80[2.54-9.08], for 20, 200 and 2000-fold above upper reference limit, respectively). A prognostic risk score developed using these parameters showed good performance; 30-days primary outcome incidence increased gradually from 3.9%(risk-score=0) to 81.3%(risk-score≥4). This risk-score was externally validated in two independent French and US cohorts. This risk score was used prospectively in the external French cohort to identify low risk patients who were managed with no immunosuppression resulting in no cardio-myotoxic events. Conclusions: ICI-myocarditis can manifest with high morbidity and mortality. Myocarditis severity is associated with magnitude of troponin, thymoma, low-QRS voltage, depressed LVEF, and cardio-muscular symptoms. A risk-score incorporating these features performed well. Trial registration number: NCT04294771 and NCT05454527.

Racial and Ethnic Disparities in All-Cause and Cardiovascular Mortality Among Cancer Patients in the U.S.

Background: With improved cancer survival, death from noncancer etiologies, especially cardiovascular disease (CVD) mortality, has come more into focus. Little is known about the racial and ethnic disparities in all-cause and CVD mortality among U.S. cancer patients. Objectives: This study sought to investigate racial and ethnic disparities in all-cause and CVD mortality among adults with cancer in the United States. Methods: Using the Surveillance, Epidemiology, and End Results (SEER) database from years 2000 to 2018, all-cause and CVD mortality among patients ≥18 years of age at the time of initial malignancy diagnosis were compared by race and ethnicity groups. The 10 most prevalent cancers were included. Cox regression models were used to estimate adjusted HRs for all-cause and CVD mortality using Fine and Gray's method for competing risks, as applicable. Results: Among a total of 3,674,511 participants included in our study, 1,644,067 (44.7%) died, with 231,386 (6.3%) deaths as a result of CVD. After adjusting for sociodemographic and clinical characteristics, non-Hispanic (NH) Black individuals had both higher all-cause (HR: 1.13; 95% CI: 1.13-1.14) and CVD (HR: 1.25; 95% CI: 1.24-1.27) mortality, whereas Hispanic and NH Asian/Pacific Islander had lower mortality than NH White patients. Racial and ethnic disparities were more prominent among patients 18 to 54 years of age and those with localized cancer. Conclusions: Significant racial and ethnic differences exist in both all-cause and CVD mortality among U.S. cancer patients. Our findings underscore the vital roles of accessible cardiovascular interventions and strategies to identify high-risk cancer populations who may benefit most from early and long-term survivorship care.

Atrial Fibrosis by cardiac MRI is a correlate for atrial stiffness in patients with atrial fibrillation.

Aims: A relationship between left atrial strain and pressure has been demonstrated in many studies, but not in an atrial fibrillation (AF) cohort. In this work, we hypothesized that elevated left atrial (LA) tissue fibrosis might mediate and confound the LA strain vs. pressure relationship, resulting instead in a relationship between LA fibrosis and stiffness index (mean pressure/LA reservoir strain). Methods and Results: Sixty-seven patients with AF underwent a standard cardiac MR exam including long-axis cine views (2 and 4-ch) and a free-breathing high resolution three-dimensional late gadolinium enhancement (LGE) of the atrium (N=41), within 30 days prior to AF ablation, at which procedure invasive mean left atrial pressure (LAP) was measured. LV and LA Volumes, EF, and comprehensive analysis of LA strains (strain and strain rates and strain timings during the atrial reservoir, conduit and active phases) were measured and LA fibrosis content (LGE (ml)) was assessed from 3D LGE volumes. LA LGE was well correlated to atrial stiffness index (LA mean pressure/LA reservoir strain) overall (R=0.59, p<0.001), and among patient subgroups. Pressure was only correlated to maximal LA volume (R=0.32) and the time to peak reservoir strain rate (R=0.32), among all functional measurements. LA reservoir strain was strongly correlated with LAEF (R=0.95, p<0.001) and LA minimum volume (r=0.82, p<0.001). Conclusion: In our AF cohort, pressure is correlated to maximum LA volume and time to peak reservoir strain. LA LGE is a strong marker of stiffness.

Scientific document development standards for the society of cardiovascular computed tomography (SCCT): A statement from the SCCT Guidelines Committee.

The Society of Cardiovascular Computed Tomography (SCCT) is an international community of physicians, scientists and technologists advocating for research, education, and clinical excellence in the use of cardiovascular computed tomography (CCT). SCCT members are committed to improving health outcomes through effective use of CCT. The SCCT routinely authors, endorses, and jointly collaborates on scientific documents that reflect the best available evidence and expert consensus supported in practice of CCT. This paper outlines SCCT's methodology for developing scientific documents. It was formulated by members of the SCCT Guidelines Committee and approved by the SCCT Board of Directors.

Advances in Coronary Computed Tomographic Angiographic Imaging of Atherosclerosis for Risk Stratification and Preventive Care.

The diagnostic evaluation of coronary artery disease is undergoing a dramatic transformation with a new focus on atherosclerotic plaque. This review details the evidence needed for effective risk stratification and targeted preventive care based on recent advances in automated measurement of atherosclerosis from coronary computed tomography angiography (CTA). To date, research findings support that automated stenosis measurement is reasonably accurate, but evidence on variability by location, artery size, or image quality is unknown. The evidence for quantification of atherosclerotic plaque is unfolding, with strong concordance reported between coronary CTA and intravascular ultrasound measurement of total plaque volume (r >0.90). Statistical variance is higher for smaller plaque volumes. Limited data are available on how technical or patient-specific factors result in measurement variability by compositional subgroups. Coronary artery dimensions vary by age, sex, heart size, coronary dominance, and race and ethnicity. Accordingly, quantification programs excluding smaller arteries affect accuracy for women, patients with diabetes, and other patient subsets. Evidence is unfolding that quantification of atherosclerotic plaque is useful to enhance risk prediction, yet more evidence is required to define high-risk patients across varied populations and to determine whether such information is incremental to risk factors or currently used coronary computed tomography techniques (eg, coronary artery calcium scoring or visual assessment of plaque burden or stenosis). In summary, there is promise for the utility of coronary CTA quantification of atherosclerosis, especially if it can lead to targeted and more intensive cardiovascular prevention, notably for those patients with nonobstructive coronary artery disease and high-risk plaque features. The new quantification techniques available to imagers must not only provide sufficient added value to improve patient care, but also add minimal and reasonable cost to alleviate the financial burden on our patients and the health care system.

Cardiac computed tomographic imaging in cardio-oncology: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). Endorsed by the International Cardio-Oncology Society (ICOS).

Cardio-Oncology is a rapidly growing sub-specialty of medicine, however, there is very limited guidance on the use of cardiac CT (CCT) in the care of Cardio-Oncology patients. In order to fill in the existing gaps, this Expert Consensus statement comprised of a multidisciplinary collaboration of experts in Cardiology, Radiology, Cardiovascular Multimodality Imaging, Cardio-Oncology, Oncology and Radiation Oncology aims to summarize current evidence for CCT applications in Cardio-Oncology and provide practice recommendations for clinicians.