How Machine Learning Might Help Improve Cardiac Imaging.

In this Medical News interview, University of California, San Francisco, cardiologist Rima Arnaout, joins JAMA Editor in Chief Kirsten Bibbins-Domingo to discuss the transformative potential of AI on cardiac imaging.

The Role of Multimodality Imaging in the Evaluation of Heart Failure and Surgical Transplant Planning of Patients with Adult Congenital Heart Disease.

Cardiac imaging is pivotal in evaluating ventricular function, residual lesions, and long-term complications in patients with adult congenital heart disease (ACHD). Longitudinal imaging in ACHD is key for the timely identification of patients requiring evaluation for advanced therapies. The guidelines recommend routine imaging surveillance. In all patients undergoing evaluation with cardiac imaging, it is critical that studies are performed at centers with expertise and that the imaging protocols are tailored to the specific condition. The authors briefly highlight the utility and diagnostic yield of different modalities, review pertinent considerations for special populations, and focus on imaging for transplant planning.

Cardiac imaging correlates and predictors of stroke in patients with atrial fibrillation: a meta-analysis.

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.

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.

Device innovation in cardiovascular medicine: a report from the European Society of Cardiology Cardiovascular Round Table.

Research performed in Europe has driven cardiovascular device innovation. This includes, but is not limited to, percutaneous coronary intervention, cardiac imaging, transcatheter heart valve implantation, and device therapy of cardiac arrhythmias and heart failure. An important part of future medical progress involves the evolution of medical technology and the ongoing development of artificial intelligence and machine learning. There is a need to foster an environment conducive to medical technology development and validation so that Europe can continue to play a major role in device innovation while providing high standards of safety. This paper summarizes viewpoints on the topic of device innovation in cardiovascular medicine at the European Society of Cardiology Cardiovascular Round Table, a strategic forum for high-level dialogue to discuss issues related to the future of cardiovascular health in Europe. Devices are developed and improved through an iterative process throughout their lifecycle. Early feasibility studies demonstrate proof of concept and help to optimize the design of a device. If successful, this should ideally be followed by randomized clinical trials comparing novel devices vs. accepted standards of care when available and the collection of post-market real-world evidence through registries. Unfortunately, standardized procedures for feasibility studies across various device categories have not yet been implemented in Europe. Cardiovascular imaging can be used to diagnose and characterize patients for interventions to improve procedural results and to monitor devices long term after implantation. Randomized clinical trials often use cardiac imaging-based inclusion criteria, while less frequently trials randomize patients to compare the diagnostic or prognostic value of different modalities. Applications using machine learning are increasingly important, but specific regulatory standards and pathways remain in development in both Europe and the USA. Standards are also needed for smart devices and digital technologies that support device-driven biomonitoring. Changes in device regulation introduced by the European Union aim to improve clinical evidence, transparency, and safety, but they may impact the speed of innovation, access, and availability. Device development programmes including dialogue on unmet needs and advice on study designs must be driven by a community of physicians, trialists, patients, regulators, payers, and industry to ensure that patients have access to innovative care.

Novel Techniques in Imaging Congenital Heart Disease: JACC Scientific Statement.

Recent years have witnessed exponential growth in cardiac imaging technologies, allowing better visualization of complex cardiac anatomy and improved assessment of physiology. These advances have become increasingly important as more complex surgical and catheter-based procedures are evolving to address the needs of a growing congenital heart disease population. This state-of-the-art review presents advances in echocardiography, cardiac magnetic resonance, cardiac computed tomography, invasive angiography, 3-dimensional modeling, and digital twin technology. The paper also highlights the integration of artificial intelligence with imaging technology. While some techniques are in their infancy and need further refinement, others have found their way into clinical workflow at well-resourced centers. Studies to evaluate the clinical value and cost-effectiveness of these techniques are needed. For techniques that enhance the value of care for congenital heart disease patients, resources will need to be allocated for education and training to promote widespread implementation.

Multimodality Imaging Approach Evaluation of the Congenital Pericardial Defect: a Contemporary Review.

PURPOSE OF REVIEW: This review presents the etiology, clinical manifestations, diagnostic approach, and treatment of congenital pericardial defects. It also highlights the critical role of echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) in the diagnosis and management approach. RECENT FINDINGS: Congenital pericardial defects are rare. Although most cases are found incidentally, some cases could potentially be associated with serious outcomes including sudden cardiac death. The diagnosis is often challenging due to non-specific clinical manifestations and electrocardiogram findings. Echocardiography is the first-line imaging investigation for the evaluation of this condition. Advanced cardiac imaging modalities, including CCT and CMR, play important adjuvant roles in establishing the diagnosis and assists with prognostication.

Novel Imaging Approaches to Cardiac Manifestations of Systemic Inflammatory Diseases: JACC Scientific Statement.

Derangements in the innate and adaptive immune responses observed in systemic inflammatory syndromes contributes to unique elevated atherosclerotic risk and incident cardiovascular disease. Novel multimodality imaging techniques may improve diagnostic precision for the screening and monitoring of disease activity. The integrated application of these technologies lead to earlier diagnosis and noninvasive monitoring of cardiac involvement in systemic inflammatory diseases that will aid in preclinical studies, enhance patient selection, and provide surrogate endpoints in clinical trials, thereby improving clinical outcomes. We review the common cardiovascular manifestations of immune-mediated systemic inflammatory diseases and address the clinical and investigational role of advanced multimodality cardiac imaging.

Latest Updates in Heart Failure Imaging.

Heart failure (HF), a challenging and heterogeneous syndrome, still remains a major health problem worldwide, despite all the advances in prevention, diagnosis, and treatment of cardiovascular disease. Cardiac imaging plays a pivotal role in the classification of HF, accurate diagnosis of underlying etiology and decision-making. Integration of other imaging techniques such as cardiac magnetic resonance, nuclear imaging, and exercise imaging testing is important to characterize HF accurately. This article reviews the role of multimodality imaging to diagnose patients with HF.

Emerging Roles for Artificial Intelligence in Heart Failure Imaging.

Artificial intelligence (AI) applications are expanding in cardiac imaging. AI research has shown promise in workflow optimization, disease diagnosis, and integration of clinical and imaging data to predict patient outcomes. The diagnostic and prognostic paradigm of heart failure is heavily reliant on cardiac imaging. As AI becomes increasingly validated and integrated into clinical practice, AI influence on heart failure management will grow. This review discusses areas of current research and potential clinical applications in AI as applied to heart failure cardiac imaging.

The year 2022 in the European Heart Journal-Cardiovascular Imaging: Part I.

The European Heart Journal-Cardiovascular Imaging with its over 10 years existence is an established leading multi-modality cardiovascular imaging journal. Pertinent publications including original research, how-to papers, reviews, consensus documents, and in our journal from 2022 have been highlighted in two reports. Part I focuses on cardiomyopathies, heart failure, valvular heart disease, and congenital heart disease and related emerging techniques and technologies.

A novel reconstruction method combining multi-detector SPECT with an elliptical orbit and computer tomography for cardiac imaging.

The myocardial single photon emission computed tomography (SPECT) is a good study due to its clinical significance in the diagnosis of myocardial disease and the requirement for improving image quality. However, SPECT imaging faces challenges related to low spatial resolution and significant statistical noise, which concerns patient radiation safety. In this paper, a novel reconstruction system combining multi-detector elliptical SPECT (ME-SPECT) and computer tomography (CT) is proposed to enhance spatial resolution and sensitivity. The hybrid imaging system utilizes a slit-slat collimator and elliptical orbit to improve sensitivity and signal-to-noise ratio (SNR), obtains accurate attenuation mapping matrices, and requires prior information from integrated CT. Collimator parameters are corrected based on CT reconstruction results. The SPECT imaging system employs an iterative reconstruction algorithm that utilizes prior knowledge. An iterative reconstruction algorithm based on prior knowledge is applied to the SPECT imaging system, and a method for prioritizing the reconstruction of regions of interest (ROI) is introduced to deal with severely truncated data from ME-SPECT. Simulation results show that the proposed method can significantly improve the system's spatial resolution, SNR, and image fidelity. The proposed method can effectively suppress distortion and artifacts with the higher spatial resolution ordered subsets expectation maximization (OSEM); slit-slat collimation.

Pathway for the Diagnosis and Management of Cardiac Amyloidosis.

The systemic amyloidoses are a broad spectrum of diseases that result from misfolding of proteins that aggregate into amyloid fibrils. In cardiac amyloidosis, amyloid fibrils accumulate in the interstitial space between cardiac myocytes causing cellular injury and impairing compliance. Current data suggest that cardiac amyloidosis is more common than previously thought. Advances in cardiac imaging, diagnostic strategies, and therapies have improved the recognition and treatment of cardiac amyloidosis. A position statement for the diagnosis and treatment of cardiac amyloidosis has been published in 2021 by the European Society of Cardiology and an expert consensus decision pathway was published in 2023 by the American College of Cardiology. These are excellent documents but quite lengthy and complex. For this reason, our team developed a novel and simple pathway to help health care providers diagnose and treat patients with cardiac amyloidosis. Our pathway starts with a section titled "suspicion" in which we provide simple clues or "red flags" that are associated with the cardiac amyloidosis phenotype. It is followed by a section titled "diagnosis," where we present in a simplified 2 × 2 format the laboratory and imaging tests that must be performed for an accurate diagnosis. In the section titled "treatment," we describe the 4 pillars in the management of patients with cardiac amyloidosis, which includes the following: heart failure treatments, management of arrhythmias, treatment of significant aortic stenosis, and appropriate selection of disease modifying therapies. Our algorithm ends with our simplified recommendation for follow-up.

Role of cardiac imaging in management of heart failure.

The significant advancement in cardiac imaging in recent years led to improved diagnostic accuracy in identifying the specific causes of heart failure and also provided physicians with guidelines for appropriately managing patients with heart failure. Diseases that were once considered rare are now more easily detected with the aid of cardiac imaging. Various cardiac imaging techniques are used to evaluate patients with heart failure, and each technique plays a distinct yet complementary role. This review aimed to discuss the comprehensive role of different types of cardiac imaging in the management of heart failure.

Diagnosis and management of patients with left ventricular hypertrophy: Role of multimodality cardiac imaging. A scientific statement of the Heart Failure Association of the European Society of Cardiology.

Left ventricular (LV) hypertrophy consists in an increased LV wall thickness. LV hypertrophy can be either secondary, in response to pressure or volume overload, or primary, i.e. not explained solely by abnormal loading conditions. Primary LV hypertrophy may be due to gene mutations or to the deposition or storage of abnormal substances in the extracellular spaces or within the cardiomyocytes (more appropriately defined as pseudohypertrophy). LV hypertrophy is often a precursor to subsequent development of heart failure. Cardiovascular imaging plays a key role in the assessment of LV hypertrophy. Echocardiography, the first-line imaging technique, allows a comprehensive assessment of LV systolic and diastolic function. Cardiovascular magnetic resonance provides added value as it measures accurately LV and right ventricular volumes and mass and characterizes myocardial tissue properties, which may provide important clues to the final diagnosis. Additionally, scintigraphy with bone tracers is included in the diagnostic algorithm of cardiac amyloidosis. Once the diagnosis is established, imaging findings may help predict future disease evolution and inform therapy and follow-up. This consensus document by the Heart Failure Association of the European Society of Cardiology provides an overview of the role of different cardiac imaging techniques for the differential diagnosis and management of patients with LV hypertrophy.

Proposed competencies for the performance of cardiovascular computed tomography in pediatric and adult congenital heart disease.

Cardiovascular computed tomography (CCT) is rated appropriate by published guidelines for the initial evaluation and follow up of congenital heart disease (CHD) and is an essential modality in cardiac imaging programs for patients of all ages. However, no recommended core competencies exist to guide CCT in CHD imaging training pathways, curricula development, or establishment of a more formal educational platform. To fill this gap, a group of experienced congenital cardiac imagers, intentionally inclusive of adult and pediatric cardiologists and radiologists, was formed to propose core competencies fundamental to the expert-level performance of CCT in pediatric acquired and congenital heart disease and adult CHD. The 2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography (1) for adult imaging were used as a framework to define pediatric and CHD-specific competencies. Established competencies will be immediately relevant for advanced cardiac imaging fellowships in both cardiology and radiology training pathways. Proposed future steps include radiology and cardiology society collaboration to establish provider certification levels, training case-volume recommendations, and continuing medical education (CME) requirements for expert-level performance of CCT in pediatric and adult CHD.