Atrial Volume Research Articles

Echocardiographic evaluation of cardiac remodelling in a cohort of patients with heart failure and reduced ejection fraction treated with dapagliflozin

Abstract Background Several mechanisms have been proposed to explain SGLT2 inhibitors’ (SGLT2i) beneficial effects in patients with heart failure (HF), but their exact mode of action in this setting is not fully understood. Pivotal randomised clinical trials regarding this class of drugs in HF setting have not reported echocardiographic data regarding potential cardiac positive remodelling. Objectives To assess the effects of dapagliflozin treatment initiation on cardiac remodelling in patients with HF and reduced ejection fraction (HFrEF), with a focus on left ventricular performance and atrial volumetry. Methods In this retrospective observational study, we analysed data from 94 patients with HFrEF in whom dapagliflozin had been prescribed as part of HF treatment optimization. Inclusion criteria were: age > 18 years; ongoing optimal medical therapy (OMT) for HF according to 2021 ESC HF guidelines (except for SGLT2i); transthoracic echocardiogram within 30 days of baseline assessment demonstrating a left ventricular (LV) ejection fraction (EF) <40%; comprehensive assessment at 6 months with clinical, laboratory and echocardiographic data. Results Patients (mean age 71.7 ± 9.8, 76% males, coronary artery disease as HFrEF main aetiology in 66%) showed significant cardiac remodelling after dapagliflozin initiation, specifically in terms of stroke volume index (SVi, +9.7 ml/m2, p<0.001), LVEF (+5.1%, p<0.001), LV end-diastolic volume (LV EDV) index (-8.4 ml/m2, p<0.001), left atrial (LA) volume index (-3.9 ml/m2, p=0.026), and LV mass index (LVMi, -12.9 gr/m2, p=0.004). BNP tended to significantly decrease (-168.6 ng/L, p=0.025). Percentage of patients with an indication for ICD implantation in primary prevention went from 36.2% to 8.5%, p<0.001. We did not observe significant differences in terms of mitral regurgitation (MR) grading at follow-up (in particular, the proportion of patients with severe MR remained approximately stable: 7% vs 4%, p=0.86). We did not observe any change in diastolic function measured by E/e’ ratio (mean difference -0.6; 95% CI -2.2 to 0.9, p=0.41). Conclusions Treatment with dapagliflozin resulted in positive remodelling in our cohort of patients with HFrEF in terms of chamber volumes, contractility parameters (and this was not explained by an improvement in MR severity) and LVMi. There was a significant decrease in natriuretic peptide as well as in the proportion of patients with primary prevention ICD indication. Our findings highlight the need of further data to fully elucidate the exact mechanism that leads to LA and LV positive remodelling with SGLT2i.Figure 1.Change in TTE Parameters

Impact of epicardial adipose tissue and atrial functional impairment in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement

Abstract Background Recent studies outlined the additional prognostic value of atrial function in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). At the same time, increased epicardial adipose tissue (EAT) volumes have proven impact on atrial functional impairment in cardiovascular disease by nurturing adverse atrial remodelling. Purpose To explore the impact of increased EAT volumes as a potential pathomechanistic factor of atrial functional impairment in patients with severe AS undergoing TAVR. Methods 146 patients with severe AS underwent cardiac magnetic resonance (CMR) within 48h prior to TAVR between January 2017 and June 2021. Image analyses included myocardial volume quantification as well as CMR-feature-tracking derived strain. EAT volumes were manually delineated on short axis stacks in end-diastolic cardiac phases and indexed to body surface area. Functional and morphological parameters were compared between patients with high and low EAT volumes. Associations between morphological and functional parameters and EAT were tested using a multivariable linear regression model including patient specific parameters. Results After dichotomization at the median of 46.5ml/m2 total EAT volume, patients were assigned to high- and low-EAT groups accordingly. There was comparable age and body mass index and similar rates of co-morbidities such as hypertension, diabetes and atrial fibrillation in both groups. We observed a higher number of male patients in the high-EAT group (36 [53%] vs. 50 [72%], p=0.018). Regarding left and right ventricular dimensions and function, no differences could be shown. Left atrial (LA) end-systolic volumes were significantly higher in the high-EAT group (29.4ml/ml² [19.7-39.4] vs. 40.9ml/ml² [30.2-59.3], p=0.008), while there were no significant differences in end-diastolic volumes. Furthermore, LA reservoir strain was significantly lower in the high-EAT group compared to the low-EAT group (18.0% [11.7-21.0] vs. 11.8% [7.7-16.4], p=0.008) and was independently associated with higher EAT volumes (p=0.018) irrespective of cardiovascular risk factors and left ventricular (LV) systolic function in a multivariable regression model. Conclusion In patients with severe AS undergoing TAVR, increased EAT volumes are associated with both, morphological and functional changes of the atria. As impaired atrial function was previously shown to be an important predictor of mortality in TAVR patients, those results potentially render EAT as an additional pathomechanistic link between atrial remodelling and worse outcome in TAVR patients.

The impact of pulmonary fibrosis on cardiac function in chronic obstructive pulmonary disease

Abstract Background Emerging evidence indicates the coexistence pulmonary fibrosis and emphysema in patients with Chronic Obstructive Pulmonary Disease (COPD). The effect of pulmonary fibrosis on cardiac structure and function in COPD patients remains unclear. Purpose This study aimed to examine the association between the degree of pulmonary fibrosis identified on Computed Tomographic (CT) imaging and echocardiographic measures of cardiac structure and function in individuals with COPD. Methods The study included 456 individuals with COPD, participating in a large prospective cohort study. Patients with available CT scans and echocardiograms were included. Local histogram-based assessments of lung density were utilized to determine the percentage of fibrosis. Fibrosis was defined based on the CT attenuation within the range of -600 and -250 Hounsfield units. The association between percent fibrosis and measures of cardiac structure and function were investigated by univariable and multivariable linear regression models. Multivariable adjustments included age, sex, body mass index (BMI), and smoking. In addition, restricted cubic splines were generated to visually present the relationship between the percentage of fibrosis and specific echocardiographic parameters. Results The mean age was 71 (± 8 years), 48% were female, and the median BMI was 27 kg/m2 (IQR: 22; 30kg/m2). The mean forced expiratory volume in 1 second as a percentage of the predicted value (FEV1pp) was 47% (±18%). The mean forced vital capacity of predicted value was 71% (± 19%). The median percentage of fibrosis in the cohort was 4.9% (IQR: 3.9; 6.0%). Patients were stratified into tertiles based upon fibrosis percentage. BMI, frequency of diabetes, and FEV1pp were increasingly positively associated with fibrosis. Furthermore, significant trends for echocardiographic measures found that the patients with the most extensive fibrosis were seen to have impaired left ventricular (LV) ejection fraction (LVEF), lower absolute global longitudinal strain (GLS), increased left atrial (LA) volume index (LAVi), and higher LV mass as compared to those with less significant fibrosis. There were no significant differences between tertiles of fibrosis and age or sex. In univariable linear regression, significant inverse associations between the percentage of fibrosis, LVEF, GLS, and tricuspid annular plane systolic excursion (TAPSE) were seen (Table). For LV mass index and LAVi, significant direct associations were found (Table). After adjusting for potential confounding factors, only GLS and LAVi remained associated with pulmonary fibrosis (Figure). Conclusion This study found that GLS and LA volume were significantly associated with the degree of pulmonary fibrosis, even after adjusting for confounding variables. This may suggest that fibrosis is primarily linked with impaired left-sided measures of cardiac structure and function.Linear Regression ModelsCubic Spline Curves

Prognostic impact of left atrial reverse remodeling in patients with ADHF-HFpEF regardless of atrial fibrillation -PURSUIT-HFpEF Registry-

Abstract Background Left atrial (LA) dilatation is associated with increased mortality in patients with cardiovascular disease including heart failure (HF) and LA reverse remodeling (LARR) was reported to be associated with favorable outcomes in patients with HF. However, it remains to be clarified whether LARR could have prognostic value in patients with HF with preserved ejection fraction (HFpEF). Purpose The purpose of this study is to elucidate whether LARR is associated with clinical outcome in patients with HFpEF in relation to the presence of atrial fibrillation (AF). Methods We prospectively studied 492 patients with acute decompensated heart failure with preserved ejection fraction (ADHF-HFpEF) without the poor outcome during the first year postdischarge. Echocardiography was performed just before discharge and at 1 year after discharge. LARR was defined as the reduction of 15% or more in left atrial end-systolic volume (LAV). The primary outcome was rehospitalization for worsening heart failure. Results All study patients were divided into 2 groups according to the presence of AF at discharge (AF group, n=182 and non-AF group, n=310). During a mean follow-up period of 1.4±1.2 years, 78 patients were rehospitalized for worsening heart failure (37 patients in AF group and 41 in non-AF group). ΔLAV, the degree of reduction in LAV during the first year postdischarge, was significantly independently associated with primary outcome after multivariable adjustment both in AF group (p=0.033, HR 0.992 [0.984-0.999]) and non-AF group (p=0.021, HR 0.986 [0.974-0.998]). Kaplan-Meier analysis revealed that patients with LARR had significantly lower risk for primary outcome than those without LARR not only in the whole study patients (8% vs 20%, p=0.001) but also both in AF group (9% vs 24% p=0.013) and in non-AF group (8% vs 16% p=0.043). Among clinical characteristics during the index hospitalization, the presence of AF and prior HF hospitalization were significantly independently associated with LARR at multivariate Cox logistic regression analysis (p=0.006, OR 0.554 [0.364-0.843] and p=0.007, OR 0.491 [0.292-0.826], respectively). Conclusion(s) The left atrial reverse remodeling could have the prognostic impact in patients with ADHF-HFpEF regardless of the presence of atrial fibrillation.Kaplan-Meier curves in AF and non-AF

Echocardiographic signs of atrial cardiopathy and MRI-detected silent brain infarcts in a middle-aged cohort: the Akershus Cardiac Examination 1950 Study

Abstract Background Atrial fibrillation (AF) is linked to clinical stroke and silent brain infarction (SBI). In the majority of AF patients, there exists a recognized form of atrial cardiopathy, and it is suggested that atrial cardiopathy, even in the absence of AF, may serve as a risk factor for stroke. However, existing evidence is limited, and it remains unclear whether atrial cardiopathy indeed poses a risk for stroke and SBI. Purpose We aimed to investigate the association between echocardiographic signs of atrial cardiopathy and the detection of SBI through magnetic resonance imaging (MRI) in a middle-aged cohort from the general population. Methods In the prospective Akershus Cardiac Examination (ACE) 1950 Study conducted within the general population in Norway, cardiovascular risk assessment including transthoracic echocardiography, was undertaken at study inclusion between 2012 and 2015. We assessed body surface area-indexed left atrial (LA) maximum and minimum volume, as well as LA reservoir and contractile strain. Subsequently, brain MRI was conducted in a subset of the cohort between 2017 and 2023. SBI was defined as presence of neuroimaging sign of infarcts, including lacunes, in individuals without a history of stroke. Logistic regression analyses were performed to explore the associations between echocardiographic measures of atrial cardiopathy and SBI on MRI, adjusting for sex, age, hypertension, and diabetes. Results A total of 397 out of 3706 (10.7%) participants in the ACE 1950 study underwent MRI examination and were included in this analysis. At the time of MRI, the mean age was 70.0±2.2 years, with 157 (40%) women, 248 (62%) with hypertension, and 36 (9%) with diabetes at study inclusion. SBI was present in 51 (13%), of which only 1 (2%) had known AF. After excluding 18 participants with pre-existing AF, no significant difference were observed in LA volumes or LA strain between participants with or without SBI (Figure 1). In unadjusted and adjusted logistic regression analyses, neither LA volume nor LA strain were associated with SBI (Table 1). Conclusion Echocardiographic signs of atrial cardiopathy were not associated with silent brain infarcts in a middle-aged cohort from the general population.

Left atrial morpho-functional parameters and their correlation with other phenotypic and functional characteristics of hypertrophic cardiomyopathy

Abstract Background Left atrial (LA) volume index (LAVI), LA reservoir strain (LARS) and total atrial conduction time (TACT) (estimated by tissue Doppler imaging) are morphological and functional parameters reflecting LA structural and electrical remodeling, connected to atrial fibrillation development and heart failure progression in various substrates. In hypertrophic cardiomyopathy (HCM), correlation of the above-mentioned parameters with other disease characteristics is not fully investigated. Purpose Aim of this study was to estimate the prevalence of atrial myopathy characteristics such as increased LAVI, impaired LARS and elongated TACT in a cohort of HCM patients without AF history and investigate their correlation with other phenotypic and functional characteristics of the disease such as left ventricular (LV) hypertrophy magnitude, fibrosis extent and diastolic dysfunction grade. Methods We included 100 HCM patients (54±21 years, 75% male, maximum wall thickness 19±3.4mm) without history of atrial fibrillation who have consecutively undergone 2D-speckle tracking echocardiography and cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE). TACT and LARS measurement is shown on left panel. Burden of fibrosis (percentage of LV mass) was defined by LGE extent (>5 standard deviations compared to nulled myocardium) in CMR slices. Results All HCM patients had preserved EF (60±7.5%), while 28 (28%) presented outflow tract obstruction and 10 (10%) diastolic dysfunction stage≥2. LGE was observed in 64 patients (64%) occupying 8±5% of left ventricular (LV) mass. Mean TACT was 140±22 msec, with LAVI being 32±16 mL/m2 and LARS 26±14%. Among HCM demographic, phenotypic and functional characteristics tested, age and LV mass index were found to be the only independent regressors of TACT (r=0.54, p<0.0005 and r=0.44, p=0.002 respectively, right upper panel), while E/E’ (r=-0.44, p=0.003) and fibrosis extent (r=0.36, p=0.02) were the strongest predictors of LARS and LAVI values respectively (right lower panel). Conclusions Atrial myopathy parameters seem to correlate with various morphological and functional characteristics of HCM. Atrial electro-mechanical delay assessed through TDI based TACT correlates significantly with LVMI, whereas LARS and LAVI are strong regressors of elasticity properties, partially expressed through diastolic function and underlying fibrosis.

Left atrial appendage volume estimated by artificial intelligence predicts atrial fibrillation recurrence after cryobaloon ablation

Abstract Background/Introduction The volume of the left atrial appendage (LAA), as measured in contrast-enhanced cardiac computed tomography (CCTA), has been previously reported as a predictor of long-term recurrence of atrial fibrillation (AF) following cryoballoon ablation procedures. Unfortunately manual assessment of LAA volume, is tedious and time-consuming, making it impractical for clinical practice. The recent advent of artificial intelligence (AI)-based methods offers a potential solution to this limitation. Purpose This study aims to evaluate the utility of LAA volume, as automatically measured by a state-of-the-art AI model for the fully automatic segmentation of LAA in CCTA, in predicting AF recurrence following cryoballoon ablation procedures. Methods We retrospectively analyzed a cohort of patients who underwent cryoballoon ablation for pulmonary vein isolation at our facility between 2010 and 2016. AF recurrence was determined through in-person visits and Holter monitoring at 3, 6, and 12 months post-ablation, followed by annual visits. The first three months post-ablation were considered a blanking period. An open-source deep neural network AI model [1] was utilized to perform automatic segmentation and calculation of LAA and left atrium (LA) volumes in. Receiver-operating characteristic curves were used to obtain optimal cut-off values for increased LAA and LA volumes. We then assessed the association of increased LAA and LA volume, and the LAA to LA volume ratio with recurrence-free survival using the Cox regression model. Results The cohort consisted of 212 patients (median age 62, inter-quartile range [IQR]: 55–65), with 25% having persistent AF before the procedure. Subjects were observed for a median period of 12 months (IQR: 12–36), with 70 of them (33%) experiencing a documented recurrent AF episode. The optimal thresholds for predicting AF recurrence were established as 9.8ml for LAA volume, 124ml for LA volume, and 0.086 for the LAA to LA volume ratio, respectively. An increased LAA volume demonstrated the strongest association with AF recurrence (hazard ratio [HR]: 2.6, 95% confidence interval [CI]: 1.55–4.2), followed by an increased LA volume (HR: 2.1, 95% CI: 1.3–3.4), persistence of AF (HR: 2, 95% CI: 1.2–3.3), and increased LAA to LA volume ratio (HR: 1.9, 95% CI: 1.1–3). Kaplan-Meier plots illustrating AF-free survival, are presented in Figure 1. After adjusting for age, persistent AF, left ventricular ejection fraction, and body surface area, all AI measurements remained significantly associated with a higher AF recurrence (Table 1). Conclusions Increased LAA volume, as assessed automatically by AI in CCTA, is a useful predictor of AF recurrence after catheter ablation for atrial fibrillation. The use of freely available, AI-assisted analysis of CCTA could be instrumental in assessing LAA volume, among other predictors, for long-term ablation success.Figure 1.

Systemic manifestations of connective tissue abnormalities in patients with Mitral Valve Prolapse assessed by Cardiac Magnetic Resonance

Abstract Background Mitral valve prolapse (MVP) reflects a connective tissue abnormality of the mitral leaflets leading to myxomatous degeneration. Early echocardiography and semeiotic assessment investigations suggested that connective tissue abnormalities might be extended to heart chambers, great vessels, and the skeletal system. Cardiac Magnetic Resonance (CMR) has unique potentials in evaluating MVP, cardiac chambers, aortic dimensions, and Haller Index, an expression of the deformity of the thoracic cage, at one time. Purpose We aimed to investigate the potential phenotypic systemic expressions of connective tissue disease in patients with MVP by CMR assessment. Methods This case-control study included consecutive patients with MVP and a control group of healthy volunteers undergoing CMR at our Institution from September 2020 to November 2023. Patients with more than mild mitral or aortic regurgitation, bicuspid aortic valve, or known systemic connective diseases were excluded. The MVP, cardiac chambers, aortic dimensions, and Haller Index were assessed according to standard practice. Results 103 patients with MVP and 57 healthy volunteers (51± 17 vs. 47±18 years, p=0.2, and 5% females vs. 54.4% females, p=0.8, respectively) were enrolled. Patients with MVP showed greater left ventricular end-diastolic (91±25 vs. 78±17 ml/m2; p=0.005) and end-systolic volumes (36±12 vs. 27±6; ml/m2; p<0.001), aortic annulus (13±2 vs. 12±2 mm/m2; p<0.001), sino-tubular junction (15±3 vs. 14±3 mm/m2; p=0.03), aortic root (19±3 vs. 17±3 mm/m2; p<0.001), and descending aorta (13±2 vs. 12±2 mm/m2; p=0.03), and higher Haller Index (2.8±0.6 vs. 2.6±0.4; p=0.02) than healthy controls. No differences were found in ascending aorta (18±3 vs. 17±3 mm/m2; p=0.3), pulmonary trunk (13±2 vs. 13±2 mm/m2; p=0.5), left atrial volume (38±18 vs. 30±15 ml/m2; p=0.20), right ventricular end-diastolic-volume (86±20 vs. 81±20 ml/m2; p=0.3) were found. At ANCOVA, sex and MVP affected the Haller Index values (p = 0.005 and 0.04). The association between MVP and Haller Index persisted after controlling for sex, age, and body surface area. In multivariate regression analysis, MVP and sex had an independent impact on ventricular and aortic dimensions, with MVP and male patients showing greater values. In particular, MVP was associated with an increase in the aortic annulus (Coefficient=1.2; p< 0.001), aortic root (Coefficient=1.5, p=0.001), descending aorta (Coefficient=0.7, p = 0.026), left ventricular end-diastolic-volume (Coefficient=11.1, p=0.01) and mass (Coefficient=5.7, p=0.02) after controlling for sex, age, and body surface area. Conclusions This pivotal study assessing systemic connective tissue disorders by CMR suggests abnormalities in the aorta and the skeletal system of patients with MVP, paving the way to larger investigations exploring the clinical impact of these findings.CMR findings in the study populationBox plots showing variables distribution

Determinants of right ventricular - pulmonary arterial uncoupling in hypertrophic cardiomyopathy

Abstract Background Right ventricular (RV) – pulmonary arterial (PA) coupling, assessed by echocardiography, is a non-invasive surrogate on how the RV is adapted to an increased afterload in the pulmonary circulation. In cases of exhaustion of compensatory RV remodeling, the ratio decreases and there is RV-PA uncoupling. Our objective was to identify what are the determinants of this parameter in patients with hypertrophic cardiomyopathy (HCM). Methods This prospective cohort study enrolled patients with HCM without obstructive epicardial coronary artery disease, that underwent a comprehensive evaluation. Echocardiography was used to assess RV-PA coupling as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP). In addition, coronary flow reserve in the left anterior descending artery (CFR_LAD) was also evaluated: diastolic coronary flow velocity was measured in basal conditions and in hyperemia and CFR was calculated as the ratio of hyperemic and basal peak diastolic flow velocities. This was used as a surrogate marker of coronary microvascular dysfunction. Cardiac magnetic resonance (CMR) was also performed to evaluate RV function (volumes and ejection fraction), and the extent of late gadolinium enhancement (LGE) in the left ventricle (LV). Results We enrolled 62 patients, with a mean age of 55 (15) years, 64% males. In 64% it was an asymmetrical septal hypertrophy phenotype, in 31% an apical hypertrophy, and in 27%, it was an obstructive HCM. Mean TAPSE/PASP was 0.556 (0.23) and median was 0.50. All patients had a normal LV ejection fraction. Univariable linear regression analysis showed that age, maximal wall thickness, E/E’, indexed left atrial volume (LAVi), CFR-LAD, %LGE and % hypoperfusion (by CMR) were correlated with RV-PA uncoupling. The HCM phenotype or the presence of obstruction were not associated with uncoupling. Multivariable stepwise linear regression analysis showed that the independent predictors of RV-PA uncoupling were age (b-estimate: - 0.180, p=0.009), LAVi (b-estimate: -0.645, p=<0.001), CFR-LAD (b-estimate: 0.183, p=0.011) and %LGE (b-estimate: -0.270, p=<0.001). Conclusion In patients with HCM, the presence of coronary microcirculation abnormalities and the extent of LGE in the LV are independent predictors of RV-PA uncoupling.

Serial changes in left atrial strain in symptomatic obstructive hypertrophic cardiomyopathy treated with mavacamten: insights from VALOR-HCM trial

Abstract Background In severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM), the VALOR-HCM phase 3 randomized, double-blind, placebo-controlled clinical trial demonstrated that mavacamten, a cardiac myosin inhibitor, reduces the eligibility for septal reduction therapy with sustained improvement in left ventricular (LV) outflow tract gradients and symptoms. Mavacamten also resulted in favorable cardiac remodeling, including improvement in left atrial volume index (LAVI), LV diastolic function, and biomarkers (NT-proBNP and troponin T). However, the impact of mavacamten on LA function is not known. Objective We sought to assess serial changes in LA strain measures in patients enrolled in the VALOR-HCM trial. Methods VALOR-HCM included 112 symptomatic obstructive HCM patients (mean age 60 years, 51% male). Patients assigned to mavacamten at baseline (n=56) continued therapy for 56 weeks and those assigned to placebo crossed over to mavacamten (n=52) from week 16-56 (40-week exposure). Echocardiographic LA strain assessment was performed according to the current American and European guideline recommendations, using a vendor-neutral post processing software. For assessment of LA strain components (reservoir, conduit, and contraction), the non-foreshortened apical 4-chamber view was utilized. The zero reference was set at end-diastole. Results Serial changes in LAVI and all components of mean LA strain from baseline to week 56 are shown in the Figure. At baseline, LAVI and all mean LA strain values were worse than reported normal mean thresholds. There was a continued and significant improvement in all 3 LA strain values, from baseline to week 56, along with a significant reduction in LAVI. Improvement in LAVI was seen earlier than improvements in LA strain. There was a significant inverse correlation between change in mean LAVI and LA reservoir strain from baseline to week 56 (r= -0.42, p<0.001). Conclusions In the VALOR-HCM trial, average LAVI and baseline LA strain values were significantly worse than reported normal thresholds. Treatment with mavacamten resulted in an improvement in LAVI and LA strain values from baseline through week 56 suggesting a sustained favorable impact on cardiac remodeling. The advantageous cardiac remodeling associated with long-term treatment with mavacamten may in turn have a favorable impact on the observed high burden of atrial tachyarrhythmias in HCM.Serial changes in LA strain in VALOR-HCM

The impact of preoperative four-chamber strain on failure of the maze IV procedure for atrial fibrillation: insights from conventional and speckle-tracking echocardiography

Abstract Background Prior studies have linked decreased left atrial (LA) and left ventricular (LV) function to the failure of both catheter ablation and surgery for atrial fibrillation (AF). Yet, the effects of right atrial (RA) and right ventricular (RV) function on the failure of interventional therapy remain unexplored. This study evaluates four-chamber strain parameters using conventional echocardiography and speckle-tracking analysis to evaluate the contributions of preoperative left heart and right heart function to the failure of surgery for atrial fibrillation. Methods We retrospectively analyzed 821 patients who had surgical AF ablation, using pre- and postoperative data from electronic records to assess AF recurrence and thromboembolic events. Of these, 531 had LA ablation only and 290 had bi-atrial Maze-IV procedures. Four-chamber strain was evaluated via speckle-tracking on preoperative echos with TomTec Arena, excluding low-quality images. Univariate and multivariate logistic regression analyses were conducted to assess the influence of AF duration, LV ejection fraction, age, and gender on post-PAF surgery AF recurrence, thromboembolic events with results shown as odds ratios (ORs) in the table. An OR over 1.00 indicates a higher recurrence risk per variable increment. SAS software was used for all statistical analysis. Results In our cohort with a median age of 67.4±11.0 (46.2% female), unadjusted analyses revealed that increased LA and RA volumes and decreased RV free wall strain were significantly associated with AF recurrence post-surgical ablation. Conversely, each unit decrease in LA and RA peak reservoir strain corresponded to a 6% increase in the risk of AF recurrence, indicating an inverse relationship. Adjusted analyses for LA and RA end diastolic volumes and strain values showed a similar direction of association with AF recurrence, though these were not statistically significant. Similarly, lower LA and RA peak strains and larger atrial volumes were suggestive of an increased risk for postoperative thromboembolic stroke, but did not reach statistical significance, potentially due to the low event rate (1.8% of the cohort). Conclusion Conventional echocardiography offers a practical tool for identifying patients at high risk for AF recurrence and potential thromboembolic events after AF ablation surgery. Our study confirms that reduced preoperative LA, RA and RV strain values and enlarged volumes of LA and RA are strongly associated with AF recurrence following surgical ablation. Additionally, RA strain and volume are as predictive as LA metrics, underscoring their importance in risk stratification. These echocardiographic parameters may also hold value in forecasting the likelihood of postoperative stroke.

Left ventricular mass index and prognosis of symptomatic severe aortic stenosis in women and men

Abstract Background Symptomatic severe aortic stenosis (AS) requires surgical (SAVR) or transcatheter aortic valve replacement (TAVR), and many patients are on the procedure waiting list. The diagnosis of severe AS is based on clinical and echocardiographic criteria, such as left ventricular ejection fraction (LVEF), aortic valve area (AVA), mean transvalvular gradient, and peak aortic jet velocity. However, there is a gap in knowledge regarding the influence of left ventricular mass on the prognosis of these patients, especially considering differences between women and men. Purpose To evaluate the influence of left ventricular mass index (LVMi) on the mortality of women and men with severe AS awaiting SAVR or TAVR. Methods A prospective study analysed the death rate in 531 outpatients with symptomatic severe AS with mean transvalvular gradient ≥40 mmHg, AVA ≤1.0 cm2, or peak aortic jet velocity ≥4.0m/s at echocardiography with the indication for TAVR or SAVR in the period from April 2020 to February 2024. Baseline data included analysis of clinical characteristics, echocardiographic variables, and the presence of coronary artery disease (CAD). Statistical analyses were performed using the Kaplan-Meier (K-M) and Cox proportional hazards methods to analyze mortality rates in women and men. Results The mean age was 74.7±11.6 years, with 283 (53.3%) men. Over a follow-up period of 2.67±1.22 years, death occurred in 165 (31.1%), 148 (86%) due to cardiovascular disease, and 152 (92%) had heart failure (HF) NYHA II to IV, 51 (9,6%) had angina, and syncope in 11 (2.1%) of the patients. Patients who died had lower LVEF (61.4%±8.9% vs. 58.8%±10.8%; p=0.008) and higher LVMi (125.3±32.5 g/m2 vs. 115.5±29.3 g/m2; p=0.001). Angina, syncope, hypertension, dyslipidemia, diabetes, smoking, atrial fibrillation, and CAD prevalence were similar in living patients and in those who died. Both groups had similar echocardiographic data, such as left atrial volume, mean transvalvular gradient, and peak jet velocity. TAVR and SAVR were done in 111 (20.9%) and 162 (30.5%) patients. Of these, 21 (18.9%) and 20 (12.4%) died during follow-up, respectively. Cumulative mortality of all patients was higher with LVMi >115 g/m2 compared to ≤115 g/m2 (p=0.008)(Figure). In women but not in men, cumulative mortality was higher with LVMi >115 g/m2 compared to ≤115 g/m2 (p=0.046). Cox multivariate analysis, adjusted for LVEF, LVMi, CAD, and age, showed LVMi as an independent variable for death [HR=1.50 (95%CI: 1.10-2.05); p=0.011]. LVEF [HR=0.97 (95%CI: 0.95-0.99); p=0.009] and LVMi [HR=1.75 (95%CI: 1.10-2.79); p=0.016] were independent variables for death in women, but not in men. Conclusion Women with higher LVMi and lower LVEF should have valve intervention prioritized.Figure

Duration of sinus rhythm after direct current cardioversion does not predict recurrence of atrial fibrillation after subsequent catheter ablation: a multicentre study

Abstract Background Catheter ablation (CA) for persistent atrial fibrillation (PsAF) is associated with high rates of AF recurrence. DC cardioversion (DCCV) is often performed before CA, with wide variation in duration of maintenance of sinus rhythm (SR) post-DCCV. Factors associated with short duration of SR after DCCV, such as raised body mass index, prior duration of AF, prolonged p wave duration on the 12-lead ECG, and indexed left atrial volume, are either associated with or indicative of atrial electrical and structural remodelling, suggesting that shorter duration of SR after DCCV reflects a more advanced substrate for AF, which could in turn also influence the likelihood of success after CA. Objective To determine if post-DCCV SR duration is associated with AF recurrence after subsequent CA. Methods We performed a multicentre retrospective study of patients undergoing first-time CA for PsAF between 2015-2018 with prior DCCV. SR duration after the last DCCV prior to CA was recorded. The primary outcome was the first recurrence of atrial arrhythmia post-CA (after a 90-day post-CA blanking period). We also performed a pre-specified sensitivity analysis for amiodarone use at DCCV, by performing repeat analysis after excluding all such patients across the three groups. Results A total of 331 patients were identified across five centres and categorised by post-DCCV SR duration: <7 days (group 1); 7-31 days (group 2); >31 days (group 3; Table 1). Over median post-CA follow-up of 591 days, 207 patients (62.5%) met the primary outcome. There was no significant between-group difference in the time to primary outcome (log rank p=0.82; Figure 1). There were significantly more blanking period arrhythmias in groups 1 and 2 than group 3 after post hoc Bonferroni correction (pairwise p=0.001, 0.002 respectively; Table 1). After exclusion of patients on amiodarone at time of DCCV, there remained no significant between-group difference in the time to primary outcome (log rank p=0.85). Conclusion Shorter duration of SR post-DCCV is associated with blanking period arrhythmia after CA, but crucially does not predict long-term AF recurrence. Early AF recurrence after DCCV should not influence decisions on CA suitability or be used to predict long-term CA success.

Children after kidney transplantation show severe cardiac alterations

Abstract Sudden cardiac death is among the most common causes of death in patients with chronic kidney diseases (CKD) after pediatric kidney transplantation (KTx), but defined diagnostic procedures identifying children at risk are not established. Echocardiographically detectable damage in the context of CKD has been described, but there are few data after KTx in childhood. The aim was to characterize structural and functional cardiac alterations on cardiac MRI (cMRI) and echocardiography in children after KTx and to elucidate the significance of diastolic dysfunction in this special context. 46 KTx recipients (mean age 16.0±3.5 years) and due to missing reference values 46 age- and sex-matched healthy controls were examined with non-contrast cMRI. Native T1 time (nT1), left ventricular mass z-score (LVMIz), ejection fraction (EF), global longitudinal strain (GLS) were measured. KTx recipients underwent comprehensive echocardiography: EF, mitral inflow (E-, A-wave), TDI e', E/e'-ratio, isovolumetric relaxation time (IVRT), pulmonary venous flow (PVFsys, PVFdia), atrial reversal (PVF-AR) and left atrial volume index (LAVI), left ventricular mass z-score (LVMz). Multivariable linear regression analysis (co-variates: age, sex, height) were used to show associations between cMRI and echo parameters. In cMRI KTx recipients had a siginficant higher nT1 than healthy controls (septal: 1198±49ms vs. 1155±23ms, p<0.0001; lateral: 1141±57ms vs. 1109±37ms, p=0.003). In KTx recipients, LVMIz was higher (0.1±1.1g/m2 vs. -0.3±0.7g/m2; p=0.026), GLS was lower than in healthy controls (-19± 2.1% vs. -20.3±2.7%, p=0.01). While based on cMRI 2 patients were diagnosed with left ventricluar hypertrophy (LVH), 11% (n=5) displayed LVH on echo. EF was preserved in all patients. However, in echocardiography, 90% (n=40) of the KTx recipients showed diastolic parameters out of the age-specific normal range (Fig.1) with changes in two or more diastolic parameters in half of the cohort. Associations with septal nT1 on cMRI could be demonstrated for septal E/e´ (ß=8.415, p=0.042), A-wave (ß=1.037, p=0.045), LAVI (ß=3.347, p=0.002) and PVF-AR (ß=2.945, p=0.021); associations with lateral nT1: septal E/e´ (ß=9.590, p=0.045) and LAVI (ß=3.393, p=0.009) (Fig. 2); 7 (15 %) had an elevated nT1 septal, lateral and E/e´ out of the normal range. Young KTx recipients show a high prevalence of diastolic dysfunction with preserved EF. Impaired diastolic function was associated with structural alterations reflecting myocardial fibrosis. Our findings suggest that a large number of children after KTx suffer from heart failure with preserved EF – an entity not yet defined in children but described for adults, in whom it is associated with sudden cardiac death. Further studies are needed to describe the clinical relevance of these findings, which gain explicit importance, as the prognosis of HFpEF in adults is improved by SGLT2i, a treatment option not yet considered in our high-risk patient group.

Tricuspid regurgitation in the context of severe concomitant left-sided valvular heart disease: patients characteristics and long-term clinical and interventional outcomes

Abstract Background The clinical features, therapeutical management and outcome of patients with significant tricuspid regurgitation (TR) in the context of multiple valvular disease (VD) are poorly defined. Purpose To assess the characteristics, management and long-term prognosis of a large cohort of patients with multiple VD, focusing on the context of significant TR and concomitant severe mitral or aortic disease. Methods Clinical and echocardiographic data were collected in 1183 patients with ≥moderate TR diagnosed at our centers from January 2012 to June 2020: after propensity score matching for age to create matched cohort with < 10% of absolute difference, 975 patients were included in this study and divided in 4 groups as shown in Figure 1. Primary endpoint was all-cause death (ACD), secondary endpoint was the composite of heart failure (HF) hospitalization+any valvular intervention. Results Patients with isolated TR (356, 37%) had more history of atrial fibrillation and were more often asymptomatic and with preserved left-ventricular ejection fraction (LVEF). TR+ severe MR patients (466, 48%) showed higher rates of concomitant coronary artery disease, NYHA class III/IV symptoms and larger left atrial volumes. The group of TR+ severe AS (131 patients, 13%) was characterized by older age, more comorbidities and lower LVEF. Patients with TR and severe AR (22, 2%) were younger, with larger LV dimensions and higher pulmonary pressures. Overall, in 37(4%) patients tricuspid intervention was performed: no differences were found between groups in term of frequency of concomitant or staged tricuspid valve surgical treatment (p=0.444 and p= 0.624, respectively), while left-valve only surgical treatment was more common among patients with TR and severe MR and left-valve transcatheter treatment among patients with TR and severe AS (both p<0.001). After a median follow-up of 2.8 years, the primary endpoint occured in 374 (38%) of patients, and was significantly more frequent in the group of patients with TR and severe AS (p<0.001, Figure 2). In this group, after multivariate analysis, indexed stroke volume remained independenty associated with ACD (OR 0.96, CI 0.93-0.98, p =0.040). Eventually, the secondary endpoint too was more common in patients with TR and severe AS (p<0.001, Figure 2). Conclusions In the context of significant TR, concomitant severe left-sided VD is common, and each subtype presents with different clinical features and echocardiographic phenotypes; in this scenario, TR was profoundly underteated. Long-term, patients with significant TR+ severe AS have considerable worse prognosis.Figure 1Figure 2

The impact of multimorbidity on cardiac remodelling in the UK Biobank

Abstract Background/Introduction Previous work has suggested that multimorbidity is associated with higher all-cause mortality and cardiovascular mortality in the UK Biobank (UKB). The impact of multimorbidity on cardiac remodelling as measured by cardiovascular magnetic resonance (CMR) has not been studied in large cohorts. Purpose To determine if CMR biomarkers act as surrogates for adverse cardiovascular outcomes in multimorbidity. Method We analysed 44957 UKB participants who had CMR. Self-reported cancer (UKB field ID 20001) and non-cancer illnesses (UKB field ID 20002) were used to calculate comorbidity count with multi-morbidity defined as 2 or more illnesses. The predictive value of comorbidity count (exposure counts measured in quintiles) on CMR traits (outcomes) was evaluated using a univariable and multivariable generalised linear model. Covariates included sex, age, BMI, smoking status, regular alcohol intake, and the Townsend deprivation index, a measure of socioeconomic deprivation. The first model utilised univariable regression without covariates with subsequent iterations including age and sex and then all covariates. An interaction term was included for age and sex and a quadratic term for age in the models. CMR outcome measures were indexed left ventricular mass (LVM), indexed left ventricular end diastolic volume (LVEDV), indexed left ventricular end systolic volume (LVESV), indexed left ventricular stroke volume (LVSV), left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), and indexed maximal left atrial volume (LA). The absolute value of GLS was used in the regression models. Variance inflation factor testing was used to check for collinearity. Analyses were completed using R v4.1.1. Results Median comorbidity count was 2. The burden of long-term conditions in this population of European ancestry with largely healthy individuals is lower than in other large population cohorts. Table 1 summarises multivariable analyses for comorbidity count, LVM and GLS. Due to high collinearity relating to age in the model, we centred age around the mean. LVM was higher with multimorbidity (top quintile Beta 0.63 (95% CI 0.23 to 1.04), P = 2.21x10-03). GLS was lower with multimorbidity (top quintile Beta -0.29 (95%CI -0.42 to 0.16), P = 8.10x10-6). LA volume was lower with multimorbidity (top quintile Beta -0.63(95% CI -1.22 to 0.04), P = 3.53 x 10-2). LVEF and other volume measures were not associated with multimorbidity. Conclusion Multimorbidity in this large cohort was associated with adverse cardiac structural and functional remodelling on CMR. These include a lower global longitudinal strain and higher LV mass.

Gender-related differences in clinical characteristics of patients with hypertrophic cardiomyopathy in our city

Abstract Background Female patients with hypertrophic cardiomyopathy (HCM) tend to display a higher rate of heart failure as well as lower survival compared to male patients. Despite this, gender-related differences in the clinical characteristics of HCM patients remain unclear. Methods and Aim Consecutive HCM patients were prospectively enrolled at a tertiary referral center. The primary objective of this study was to investigate and emphasize gender differences in clinical characteristics including imaging and laboratory parameters. Results Between May 2018 and January 2024, a total of 301 HCM patients were included, of which 41.9% were female (n=125). Female patients were significantly older and more symptomatic than male counterparts (59 years [IQR 47-67] vs. 53 years [IQR 39-61], p=0.001; New York Heart Association functional class ³III: 28.8% vs. 17.6%, p=0.002, respectively). No significant differences in body mass index were found (28.4 kg/m² [IQR 24.9-31.6] vs. 28.4 kg/m² [IQR 25.9-31.8], p=0.8). With respect to echocardiographic parameters, although interventricular septal thickness was comparable (19.0 mm [IQR 16.0-22.0] vs. 19.5 mm [IQR 17.0-22.0], p=0.4) left atrial as well as right atrial volume index were higher in women (30.0 cm³/m² [IQR 27.0-35.0] vs. 27.0 cm³/m² [IQR 24.0-30.0], p<0.001; 27.1 cm³/m² [IQR 25.4-29.3] vs. 24.7 cm³/m² [IQR 22.5-28.2], p<0.001). These findings were further supported by elevated filling pressures in female patients reflected by E/e’ ratio (16 [IQR 14-22] vs. 10 [IQR 9-12], p<0.001). Moreover, these patients showed more frequent left ventricular (LV) outflow tract obstruction (50% vs. 33%, p=0.029) which is accompanied by a slightly higher LV ejection fraction compared to men (69% [IQR 62-74] vs. 62% [IQR 55-67], p=0.004). In terms of cardiac biomarkers, female HCM patients presented with higher levels of serum N-terminal pro brain natriuretic peptide (671 pg/ml [IQR 333-1613] vs. 357 pg/ml [IQR 115-959], p<0,001) as well as lower concentrations of serum creatinine (0.84 mg/dl [IQR 0.75-0.95] vs. 0.98 mg/dl [IQR 0.87-1.15], p<0.001) whereas no differences regarding high-sensitive troponin-T levels were observed. Conclusion This single-center analysis illustrates profound gender-related differences among HCM patients in Vienna. Female patients tend to present in a more advanced clinical status, rather reflecting the phenotype of heart failure with preserved ejection fraction. Whether these findings should prompt an early HCM diagnosis in female patients with unspecific symptoms, or may result in early treatment initiation of e.g. sodium-glucose-transporter 2 inhibitors, should be part of future research.

Left atrial function predicts long-term outcome in hypertension and diabetes across genders

Abstract Introduction In the last decade, peak atrial longitudinal strain (PALS) was ascertained to be superior to conventional echocardiographic indices for secondary cardiovascular (CV) prevention. Purpose Standard and advanced echocardiography including PALS was evaluated to find predictors of prognosis in patients with arterial hypertension and/or diabetes for the optimization of primary CV prevention. Methods Hypertensive and/or diabetic patients >40 years old and in sinus rhythm who underwent a complete cardiological evaluation at our centre in 2008-2015 were retrospectively included. Personal history, physical examination, standard and advanced (speckle tracking) echocardiographic data were collected. The exclusion criteria were previous cv events or cardiac surgery, active pacemaker, more than moderate valvular regurgitation and/or stenosis, missing informed consent. All patients were followed up for a mean time of 11.2±1.3 years for the development of first atrial fibrillation (AF) episode, congestive heart failure hospitalization, transient ischemic attack, stroke, myocardial infarction/coronary revascularization, and CV death. Univariate and multivariable stepwise Cox regressions were performed to estimate Hazard Ratio (HR). Kaplan Meier curves (KM) compared the survival between patients with different ranges of Global PALS. Log-rank test was performed to compare the KM curves. Results This retrospective study included 292 adults (mean age 63.0±9.0 years, 50% female), among which 210 hypertensives and 67 diabetics. Mean left ventricular (LV) ejection fraction (EF) was 58.2±4.9%, mean GLS was -17.0±6.6%, mean left atrial volume was 52.9±24.9ml and mean PALS 29.7±11.1%. During follow up, 110 patients developed at least one cv event: 52 all-cause deaths, 28 CV deaths, 30 heart failure admissions, 31 first AF episode, 18 TIA/strokes, 25 myocardial infarction/revascularization. Dividing the population according to events occurrence, patients with events had similar EF (p= 0.06), while being older (65.8±9.6 vs 61.3±9.0 years) and with a worse diastolic function (E/E’ ratio 10.6±5.0 vs 8.7±3.6), LV longitudinal strain (GLS, -17.7±2.9 vs -15.7±3.4%) and PALS (34.6±9.9 vs 21.6±7.7%, all p <0.001). From univariate statistical analysis, age, E/E’, PAPs, GLS and PALS were all predictors of events, but only age (HR 1.03, p=0.03) and PALS (PALS<22.5% HR 18.99 and PALS 22.5-30 HR 7.68, both p<0.001) remained independently associated with outcome at multivariate analysis. Patients with PALS<22.5 have an event-free survival of 82.4% at 1 year, 49.8% at 5 years and 25.3% at 10 years compared to 100% at 1 year, 98.5% at 5 years and 92.5% at 10 years if PALS PALS>30% (Fig.1). The same results were confirmed in female population (Fig.2). Conclusions If confirmed by larger studies, PALS could be a quick, feasible and reliable part of cardiologic evaluation for prognostic stratification in primary CV prevention in hypertensive and/or diabetic patients.Fig. 1Fig. 2

Association between echocardiographic parameters and abnormal spirometry among chronic heart failure patients

Abstract Background A significant proportion (10-40%) of heart failure (HF) patients have concomitant pulmonary disease which have negative effects on cardiovascular outcome of patients. Because of the similarities in symptoms between HF and pulmonary disease, the prevalence of concomitant pulmonary disease may be underestimated. Early detection manage accordingly may improve outcomes of HF patients. We aimed to study clinical and echocardiographic parameters identifying HF patients with concomitant pulmonary disease. Methods This cross-sectional study included adults (age≥18 years) who were diagnosed with HF. The echocardiogram, arterial blood gas and pulmonary function test (PFT) were performed. The patients were classified into normal and abnormal (obstructive and restrictive) PFT patterns. The primary outcome was the association between echocardiographic parameters and abnormal PFT. The receiver operating characteristic (ROC) curve was performed to evaluate diagnostic performance of echocardiographic parameter in detecting abnormal PFT. Results A total of 57 patients was enrolled, of which 32 patients (56.14%) had normal PFT, 14 patients (24.56%) had obstructive PFT, and 11 patients (19.30%) had restrictive PFT. The clinical characteristics were not different between groups. ROC curve demonstrated that only left atrial volume index (LAVI) and main pulmonary artery (MPA) diameter had significant diagnostic accuracy to predict abnormal PFT with AUC of 0.72 (95%CI 0.57-0.87) and 0.66 (95%CI 0.51-0.80) respectively. Using combination of LAVI (cutoff 40mm2/m2) and MPA diameter (cutoff 22.0 mm) had a sensitivity of 95.7% (95%CI 78.05-99.89%) and specificity of 41.94% (95%CI 24.55-60.92%) in detection patients with abnormal PFT. Conclusion Almost half of HF had concomitant abnormal PFT. The combination of LAVI and MPA diameter can identify patients with abnormal PFT with high negative predictive value and should be considered as screening parameters in HF patients.

Associate variables of coronary computed tomographic angiography-derived extracellular volume fraction and cardiac magnetic resonance-derived late-gadolinium enhancement

Abstract Background Coronary computed tomographic angiography (CCTA) with late-iodine enhancement enables the segmental quantification of extracellular volume (ECV) fraction which represents myocardial fibrosis. However, its association with cardiac magnetic resonance (CMR)-derived late gadolinium enhancement (LGE) has not been fully elucidated. Purpose We aimed to assess the concordance and discordance between CCTA-derived ECV and CMR-derived LGE and to investigate associated variables of each index. Methods This retrospective analysis included a total of 123 segments from 41 patients (anterior, inferior and lateral segments per patient) with known or suspected coronary artery disease (CAD) who underwent both clinically indicated CCTA and CMR. Patients with cardiomyopathy such as amyloidosis were excluded. Myocardial fibrosis was evaluated by CCTA-derived segmental ECV and by CMR-LGE with ischemic pattern on a per-segment basis (AHA 16 segments). Clinical and echocardiographic variables associated with CCTA-derived segmental ECV and CMR-LGE were studied by univariable linear and logistic regression analyses, respectively. Results Among the 123 segments, 21 segments showed ischemic CMR-LGE pattern. CCTA-ECV was significantly higher in segments with versus without CMR-LGE (42 [39, 47] % versus 34 [29, 39] %, P<0.01). Receiver-operating characteristic curve analysis showed that the best cut-off of CCTA-ECV to predict CMR-LGE was 38.9% (area under the curve 0.82 [95% confidence interval 0.74, 0.90], positive predictive value: 40.0%, negative predictive value: 96.2%). Univariable analyses revealed that male sex, prior history of revascularization, usage of statin, aspirin, angiotensin-converting enzyme inhibitor and beta-blockade, higher C-reactive protein, NT-pro BNP, lower left ventricular ejection fraction, greater left ventricular chamber size, shorter deceleration time, and larger segmental and global longitudinal strain were associated with both higher CCTA-ECV and the presence of CMR-LGE. Lower lipid profiles, higher high-sense troponin I, and greater left atrial volume index were associated with higher CCTA-ECV, while not with the presence of CMR-LGE. The frequency of CMR-LGE were significantly different according to CCTA-ECV tertiles. (P<0.05) Statin use and higher NT-proBNP were determinants of the highest ECV tertile without LGE. Conclusion We found a strong interrelationship between variables associated with ECV and the presence of LGE, although high ECV may not necessarily indicate the presence of LGE in patients with known or suspected CAD. Clinical factors associated with discordance, such as high-ECV without CMR-LGE, should be taken into account in the assessment of ECV and LGE. Further studies are needed to elucidate clinical significance of the concordance and discordance between ECV and LGE.