European Association Of Cardiovascular Imaging Research Articles

Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology.

Imaging using cardiac computed tomography (CT) or magnetic resonance (MR) imaging has become an important option for anatomic and substrate delineation in complex atrial fibrillation (AF) and ventricular tachycardia (VT) ablation procedures. Computed tomography more common than MR has been used to detect procedure-associated complications such as oesophageal, cerebral, and vascular injury. This clinical consensus statement summarizes the current knowledge of CT and MR to facilitate electrophysiological procedures, the current value of real-time integration of imaging-derived anatomy, and substrate information during the procedure and the current role of CT and MR in diagnosing relevant procedure-related complications. Practical advice on potential advantages of one imaging modality over the other is discussed for patients with implanted cardiac rhythm devices as well as for planning, intraprocedural integration, and post-interventional management in AF and VT ablation patients. Establishing a team of electrophysiologists and cardiac imaging specialists working on specific details of imaging for complex ablation procedures is key. Cardiac magnetic resonance (CMR) can safely be performed in most patients with implanted active cardiac devices. Standard procedures for pre- and post-scanning management of the device and potential CMR-associated device malfunctions need to be in place. In VT patients, imaging-specifically MR-may help to determine scar location and mural distribution in patients with ischaemic and non-ischaemic cardiomyopathy beyond evaluating the underlying structural heart disease. Future directions in imaging may include the ability to register multiple imaging modalities and novel high-resolution modalities, but also refinements of imaging-guided ablation strategies are expected.

Embolic strokes of undetermined source: a clinical consensus statement of the ESC Council on Stroke, the European Association of Cardiovascular Imaging and the European Heart Rhythm Association of the ESC.

One in six ischaemic stroke patients has an embolic stroke of undetermined source (ESUS), defined as a stroke with unclear aetiology despite recommended diagnostic evaluation. The overall cardiovascular risk of ESUS is high and it is important to optimize strategies to prevent recurrent stroke and other cardiovascular events. The aim of clinicians when confronted with a patient not only with ESUS but also with any other medical condition of unclear aetiology is to identify the actual cause amongst a list of potential differential diagnoses, in order to optimize secondary prevention. However, specifically in ESUS, this may be challenging as multiple potential thromboembolic sources frequently coexist. Also, it can be delusively reassuring because despite the implementation of specific treatments for the individual pathology presumed to be the actual thromboembolic source, patients can still be vulnerable to stroke and other cardiovascular events caused by other pathologies already identified during the index diagnostic evaluation but whose thromboembolic potential was underestimated. Therefore, rather than trying to presume which particular mechanism is the actual embolic source in an ESUS patient, it is important to assess the overall thromboembolic risk of the patient through synthesis of the individual risks linked to all pathologies present, regardless if presumed causally associated or not. In this paper, a multi-disciplinary panel of clinicians/researchers from various backgrounds of expertise and specialties (cardiology, internal medicine, neurology, radiology and vascular surgery) proposes a comprehensive multi-dimensional assessment of the overall thromboembolic risk in ESUS patients through the composition of individual risks associated with all prevalent pathologies.

EACVI survey on radiation exposure in interventional echocardiography.

The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey on radiation exposure in interventional echocardiography. The survey aimed to collect data on local practices for radioprotection in interventional echocardiography and to assess the awareness of echocardiography operators about radiation-related risks. A total of 258 interventional echocardiographers from 52 different countries (48% European) responded to the survey. One hundred twenty-two (47%) participants were women. Two-thirds (76%) of interventional echocardiographers worked in tertiary care/university hospitals. Interventional echocardiography was the main clinical activity for 34% of the survey participants. The median time spent in the cath-lab for the echocardiographic monitoring of structural heart procedures was 10 (5-20) hours/month. Despite this, only 28% of interventional echocardiographers received periodic training and certification in radioprotection and 72% of them did not know their annual radiation dose. The main adopted personal protection devices were lead aprons and thyroid collars (95% and 92% of use, respectively). Dedicated architectural protective shielding was not available for 33% of interventional echocardiographers. Nearly two-thirds of responders thought that the radiation exposure of interventional echocardiographers was higher than that of interventional cardiologists and 72% claimed for an improvement in the radioprotection measures. Radioprotection measures for interventional echocardiographers are widely variable across centres. Radioprotection devices are often underused by interventional echocardiographers, portending an increased radiation-related risk. International scientific societies working in the field should collaborate to endorse radioprotection training, promote reliable radiation dose assessment, and support the adoption of radioprotection shielding dedicated to interventional echocardiographers.

Cardiovascular imaging research and innovation in 2023: a review by the Research and Innovation Committee of the European Association of Cardiovascular Imaging (EACVI)

Abstract In 2023, cardiovascular imaging has made significant advancements, in terms of technology, pathophysiology and clinical application. In this review, the most recent research findings in the field of cardiovascular imaging are discussed. Artificial intelligence, large population cohorts, together with several technical improvements, have had a crucial impact on the technological advancements of echocardiography, cardiovascular magnetic resonance (CMR), computed tomography (CT) and nuclear medicine. In the field of ischaemic heart disease, it has been demonstrated that appropriate non-invasive imaging strategies improve patients’ management, reduce invasive procedures and the need for additional testing at follow-up. Moreover, improvements in plaque characterization with CT is an expanding field of research with relevant implications for the prediction of disease severity, evolution and response to treatment. In the field of valvular heart disease, imaging techniques have advanced alongside improvements in transcatheter treatment for aortic stenosis, mitral, and tricuspid regurgitation. Finally, in the field of heart failure and cardiomyopathies, cardiovascular imaging has reinforced its crucial role in early diagnosis and risk evaluation, showcasing advanced techniques that outperform traditional methods in predicting adverse outcomes.

European Association of Cardiovascular Imaging (EACVI) survey on Cardiovascular Multimodality Imaging in Acute Myocarditis.

To assess the current role of cardiac imaging in the diagnosis, management, and follow-up of patients with acute myocarditis (AM) through an European Association of Cardiovascular Imaging survey. A total of 412 volunteers from 74 countries responded to the survey. Most participants worked in tertiary centres(56%). All participants had access to echocardiography, while 79% and 75% had access to cardiac computed tomography (CCTA) and cardiac magnetic resonance (CMR), respectively. Less than half(47%) had access to myocardial biopsy and only 5% used this test routinely. CMR was performed within 7 days of presentation in 73% of cases. Non-ischemic late gadolinium enhancement (LGE,88%) and high-signal intensity in T2-weighted images(74%) were the most used diagnostic criteria for AM. CCTA was preferred to coronary angiography by 47% of participants to exclude coronary artery disease. Systematic prescription of beta-blockers and ACEi was reported by 38% and 32% of participants. Around a quarter of participants declared considering LGE burden as a reason to treat. Most participants (90%) reported performing a follow-up echocardiogram, while 63% scheduled a follow-up CMR. The main reason for treatment discontinuation was improvement of left ventricular ejection fraction(89%), followed by LGE regression(60%). In two-thirds of participants the decision to resume high-intensity sport was influenced by residual LGE. This survey confirms the high utilization of cardiac imaging in AM, but reveals major differences in how cardiac imaging is used and how the condition is managed between centres, underlining the need for recommendation statements in this topic.

Organisation of paediatric echocardiography laboratories and governance of echocardiography services and training in Europe: current status, disparities, and potential solutions. A survey from the Association for European Paediatric and Congenital Cardiology (AEPC) imaging working group.

There is limited data on the organisation of paediatric echocardiography laboratories in Europe. A structured and approved questionnaire was circulated across all 95 Association for European Paediatric and Congenital Cardiology affiliated centres. The aims were to evaluate: (1) facilities in paediatric echocardiography laboratories across Europe, (2) accredited laboratories, (3) medical/paramedical staff employed, (4) time for echocardiographic studies and reporting, and (5) training, teaching, quality improvement, and research programs. Respondents from forty-three centres (45%) in 22 countries completed the survey. Thirty-six centres (84%) have a dedicated paediatric echocardiography laboratory, only five (12%) of which reported they were European Association of Cardiovascular Imaging accredited. The median number of echocardiography rooms was three (range 1-12), and echocardiography machines was four (range 1-12). Only half of all the centres have dedicated imaging physiologists and/or nursing staff, while the majority (79%) have specialist imaging cardiologist(s). The median (range) duration of time for a new examination was 45 (20-60) minutes, and for repeat examination was 20 (5-30) minutes. More than half of respondents (58%) have dedicated time for reporting. An organised training program was present in most centres (78%), 44% undertake quality assurance, and 79% perform research. Guidelines for performing echocardiography were available in 32 centres (74%). Facilities, staffing levels, study times, standards in teaching/training, and quality assurance vary widely across paediatric echocardiography laboratories in Europe. Greater support and investment to facilitate improvements in staffing levels, equipment, and governance would potentially improve European paediatric echocardiography laboratories.

Intraoperative and Intraprocedural Use of 3-Dimensional Transesophageal Echocardiography: An International European Association of Cardiothoracic Anesthesia and Intensive Care Survey of Cardiac Surgical Centers

ObjectiveTo assess the intraoperative use of three-dimensional transesophageal echocardiography (3D TEE) in cardiac surgical centers, we created a survey aimed at evaluating the availability of equipment, the use of 3D TEE for specific surgical and interventional procedures and single image modalities. Finally, we asked to identify the perceived impact on patient's management and current limitations to its routine use. DesignMultiple-choice 25-questions online survey submitted to the members of the European Association of Cardiothoracic Anesthesia and Intensive Care (EACTAIC) on December 6th, 2021 and closed on January 31st, 2022. SettingOnline survey. ParticipantsRegistered EACTAIC members in 2021. InterventionsNone. Measurements and Main ResultsA total of 239 respondents from 44 different countries took part in the survey (27% of total 903 EACTAIC members). Most respondents (59%) were TEE certified by National Board of Echocardiography (NBE), European Association of Cardiovascular Imaging (EACVI/EACTAIC) or had a national certificate. Sixty-eight percent of respondents had no formal 3D TEE training. Eight percent of respondents had no 3D machines. While 40% had one for each operating room, 33% had only one for the entire operating room block. 3D TEE was performed most frequently in more than 67% of cases for mitral valve (MV) surgery and in more than 54% of cases for mitral- and tricuspid clips, aortic valve- (AV), tricuspid valve- (TV) and aortic surgery. ConclusionCurrent guidelines suggest integrating 3D TEE in all comprehensive examinations. Our survey reports that intraoperative 3D TEE was used in the majority of mitral valve surgery and only half of other valve surgeries and transcatheter procedures. Its use may be explained by the availability of 3D machines, trained personnel and limited time to perform TEE in the operating room. Educational initiatives for training in 3D TEE may further increase its routine use.

Focused cardiac ultrasound: Competency among pre-internship medical officers in diagnosing cardiac causes of dyspnea.

Differentiating cardiovascular causes of dyspnea in resource-limited healthcare settings can be challenging. The use of easy-to-train, point-of-care, focused cardiac ultrasound (FoCUS) protocols may potentially alleviate this challenge. Can novices attain competency in FoCUS use after training using the cardiac ultrasound for resource-limited settings (CURLS) protocol? A quasi-experimental study was conducted at the Kenyatta National Hospital in Nairobi, Kenya. Forty-five graduate medical pre-interns, novices in cardiac ultrasound, received simulated didactic and hands-on FoCUS skills training using the CURLS protocol and 2018 European Association of Cardiovascular Imaging (EACVI) FoCUS training and competence assessment recommendations. Competency was assessed in image interpretation, image acquisition, and image quality. Aggregate image interpretation competency was attained by n = 38 (84%) of trainees with a median score of 80%. The proportion of trainees attaining category-specific image interpretation competency was as follows: pericardial effusion n = 44 (98%), left atrial enlargement n = 40 (89%), cardiomyopathy n = 38 (84%), left ventricular hypertrophy n = 37 (82%), and right ventricular enlargement n = 29 (64%). Image acquisition skills competency was attained by n = 36 (80%) of trainees. Three-quarters of trainee-obtained images were of good quality. Majority of the trainees attained competency. Training constraints limit the generalizability of our findings.

Evaluation and management of patients with coronary chronic total occlusions considered for revascularisation. A clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC, the European Association of Cardiovascular Imaging (EACVI) of the ESC, and the ESC Working Group on Cardiovascular Surgery.

Chronic total occlusions (CTOs) of coronary arteries can be found in the context of chronic or acute coronary syndromes; sometimes they are an incidental finding in those apparently healthy individuals undergoing imaging for preoperative risk assessment. Recently, the invasive management of CTOs has made impressive progress due to sophisticated preinterventional assessment, including advanced non-invasive imaging, the availability of novel and dedicated tools for CTO percutaneous coronary intervention (PCI), and experienced interventionalists working in specialised centres. Thus, it is crucial that referring physicians who see patients with CTO be aware of recent developments and of the initial evaluation requirements for such patients. Besides a careful history and clinical examination, electrocardiograms, exercise tests, and non-invasive imaging modalities are important for selecting the patients most suitable for CTO PCI, while others may be referred to coronary artery bypass graft or optimal medical therapy only. While CTO PCI improves angina and reduces the use of antianginal drugs in patients with symptoms and proven ischaemia, hibernation and/or wall motion abnormalities at baseline or during stress, the effect of CTO PCI on major cardiovascular events is still controversial. This clinical consensus statement specifically focuses on referring physicians, providing a comprehensive algorithm for the preinterventional evaluation of patients with CTO and the current evidence for the clinical effectiveness of the procedure. The proposed care track has been developed by members and with the support of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Association of Cardiovascular Imaging (EACVI), and the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery.

European Society of Cardiology Quality indicators for the care and outcomes of adults undergoing transcatheter aortic valve implantation.

To develop a suite of quality indicators (QIs) for the evaluation of the care and outcomes for adults undergoing transcatheter aortic valve intervention (TAVI). We followed the European Society of Cardiology (ESC) methodology for the development of QIs. Key domains were identified by constructing a conceptual framework for the delivery of TAVI care. A list of candidate QIs were developed by conducting a systematic review of the literature. A modified Delphi method was then used to select the final set of QIs. Finally, we mapped the QIs to the EuroHeart Data Standards for TAVI to ascertain the extent to which the EuroHeart TAVI registry captures information to calculate the QIs. We formed an international group of experts in quality improvement and TAVI, including representatives from the European Association of Percutaneous Cardiovascular Interventions, the European Association of Cardiovascular Imaging and the Association of Cardiovascular Nursing & Allied Professions. In total, 27 QIs were selected across eight domains of TAVI care, comprising 22 main (81%) and five secondary (19%) QIs. Of these, 19/27 (70%) are now being utilised in the EuroHeart TAVI registry. We present the 2023 ESC QIs for TAVI, developed using a standard methodology and in collaboration with ESC Associations. The EuroHeart TAVI registry allows calculation of the majority of the QIs, which may be used for benchmarking care and quality improvement initiatives.

Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology.

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Poor Agreement Between Preoperative Transthoracic Echocardiography and Intraoperative Transesophageal Echocardiography for Grading Diastolic Dysfunction

BACKGROUND: Guidelines for the evaluation and grading of diastolic dysfunction are available for transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE) is used for this purpose intraoperatively but the level of agreement between these 2 imaging modalities for grading diastolic dysfunction is unknown. We assessed agreement between awake preoperative TTE and intraoperative TEE for grading diastolic dysfunction. METHODS: In 98 patients undergoing cardiac surgery, key Doppler measurements were obtained using TTE and TEE at the following time points: TTE before anesthesia induction (TTEawake), TTE following anesthesia induction (TTEanesth), and TEE following anesthesia induction (TEEanesth). The primary endpoint was grade of diastolic dysfunction categorized by a simplified algorithm, and measured by TTEawake and TEEanesth, for which the weighted κ statistic assessed observed agreement beyond chance. Secondary endpoints were peak early diastolic lateral mitral annular tissue velocity (e’lat) and the ratio of peak early diastolic mitral inflow velocity (E) to e’lat (E/e’lat), measured by TTEawake and TEEanesth, were compared using Bland-Altman limits of agreement. RESULTS: Disagreement in grading diastolic dysfunction by ≥1 grade occurred in 43 (54%) of 79 patients and by ≥2 grades in 8 (10%) patients with paired measurements for analysis, yielding a weighted κ of 0.35 (95% confidence interval [CI], 0.19–0.51) for the observed level of agreement beyond chance. Bland-Altman analysis of paired data for e’lat and E/e’lat demonstrated a mean difference (95% CI) of 0.51 (−0.06 to 1.09) and 0.70 (0.07–1.34), respectively, for measurements made by TTEawake compared to TEEanesth. The percentage (95% CI) of paired measurements for e’lat and E/e’lat that lay outside the [−2, +2] study-specified boundary of acceptable agreement was 36% (27%–48%) and 39% (29%–51%), respectively. Results were generally robust to sensitivity analyses, including comparing measurements between TTEawake and TTEanesth, between TTEanesth and TEEanesth, and after regrading diastolic dysfunction by the American Society of Echocardiography (ASE)/European Association of CardioVascular Imaging (EACVI) algorithm. CONCLUSIONS: There was poor agreement between TTEawake and TEEanesth for grading diastolic dysfunction by a simplified algorithm, with disagreement by ≥1 grade in 54% and by ≥2 grades in 10% of the evaluable cohort. Future studies, including comparing the prognostic utility of TTEawake and TEEanesth for clinically important adverse outcomes that may be a consequence of diastolic dysfunction, are needed to understand whether this disagreement reflects random variability in Doppler variables, misclassification by the changed technique and physiological conditions of intraoperative TEE, or the accurate detection of a clinically relevant change in diastolic dysfunction.

Contribution of the left atrial speckle tracking in the evaluation of left ventricule filling pressure in acute coronary syndromes

Abstract Introduction A non invasive estimation of diastolic function with echocardiography according to consensual methods, ie American society of Echocardiography (ASE) / European association of cardiovascular imaging (EACVI) algorithm 2018, is considered an integral essential part of the clinical evaluation of patients presenting with symptoms of acute coronary syndrome (ACS). Left atrial (LA) longitudinal strain in the frame of speckle tracking echocardiography (STE) was reported recently to have additive diagnostic value to assess left ventricle (LV) filling pressures (LVFP) in a large spectrum of cardiovascular diseases. Our study aim is to assess the accuracy of LA strain in evaluating LVFP in patients with ACS, as a single parameter. Methods Our study was monocentric in our cardiology department led prospectively between April 20, 2022, and June 30, 2022. We included all patients admitted to our department for evolving ST elevation (STEMI) or non-ST elevation (NSTEMI) myocardial infarction (<48 hours from onset of symptoms). Echocardiographic measurements were performed according to ASE/EACVI in less than 24 hours. They were divided into two groups according to the elevation of LVFP group 1 with non-elevated LVFP vs group with elevated LVF. LA-GS was assessed using images obtained in apical 4- and 2-chamber views , with attention to optimal visualization of the LA. The endocardial border of the LA was traced manually. Left atrial reservoir strain (LARS) was calculated from LV-end diastole, and pump strain (LAPS) after the onset of the p-wave in the electrocardiogram. Results Fifty patients were included in our study. The mean age was 59 ± 12 years. 72%(36) of our population was men. 34%(17) of the population had elevated LVFP (Group2) with a male predominance of 82% (14). They were active smokers in 64% (11), 52%(9) had hypertension, 70% (12) had diabetes mellitus, 47%(8) had dyslipidemia and 35% (6) were hospitalized for NSTEMI. The mean LARS and LAPS were 26.9%, and 15.2% in group 1 vs 15.1%, and 7.1% respectively in group 2 with a difference statically significative p = 0.001, and p = 0.002 respectively. The area under the curve was 0.910 (LARS) and 0.850 (LAPS). The best cut-off for the LAPS was 11.5% with 100% of sensibility and 63% of specificity, for the LARS the best cut-off was 18% with 95% of sensibility and 66% of specificity. Conclusion LA-GS includes a reproducible and simple method for LVFP assessment in ACS. it provides an additional variable that can contribute when one of the other parameters is missing.

A preliminary study on the standard value of left ventricular mechanic dyssynchrony by speckle tracking

Abstract Background Speckle tracking imaging automatic functional imaging (AFI) is a new method to measure left ventricular mechanical dyssynchrony. Parameter peak strain dispersion (PSD) is the standard deviation when the long axial strain of 17 segments of the left ventricle (LV) reach there’s peak. There is no unified standard value at present. Li C[1] included 59 healthy women aged 43.08 ± 8.22 years old, whose PSD was 31.44±3.83ms. Ji X[2] included 57 healthy volunteers aged 43.30 ±6.03 years old whose PSD value was 23.8±2.2ms. Some studies referred to the standard range of Yu index and used PSD>32.6ms as an indicator of left ventricular mechanic dyssynchrony. Purpose To investigate the standard value range of PSD and PSD/R-R interval. Methods Healthy volunteers who came to our hospital for physical examination from March 2020 to September 2021 were included, excluding hypertension, diabetes, hyperlipidemia, coronary heart disease and other diseases. According to the 20∼29 years old, 30∼39 years old, 40∼49 years old, 50∼59 years old, 60∼69 years old and 70∼79 years old, 10 males and 10 females were included, respectively. GE Vivid E95 was used to collect echocardiographic images, and the following parameters were measured: ①The general parameters of the heart, such as the diameter of the atrium(LA) and the left ventricle (LV) and the thickness of the left ventricular wall .; ②the values of PSD and PSD/ R-R interval. The normal distribution parameters were represented by mean plus or minus the standard deviation. Analysis of variance and post hoc test (LSDt-test) were used to analyse measured values statistically. Results Values of general echocardiographic data such as BSA, atrial and ventricular diameter, interventricular septal thickness, left ventricular posterior wall thickness, and LV ejection fraction were consistent with the guideline of Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging published in 2015. The range of PSD values for subjects in this study was 43±9ms, and the maximum was 65ms. The range of PSD/R-R was 5±1%, and the maximum was 7%. The values of PSD and PSD/R-R were 36±5ms(27∼45ms) and 4.4±0.76%(3∼6.4%) for 20∼39 years old, 42±5ms(34.9-54ms), 5.0±0.8%(3.5-6.7%) in 40∼59 years; 51±8ms(34∼65ms), 5.8±0.9%(3.9∼7%) in age 60∼79. Conclusions The preliminary study has shown that left ventricular mechanical dyssynchrony is associated with age. The standard value range of PSD is inconsistent in different age groups, and PSD and PSD/R-R values increase with age.PSD values at different agesBar chart of PSD values at different age

Comparison of effective regurgitant orifice area by the PISA method and tricuspid coaptation gap measurement to identify very severe tricuspid regurgitation and stratify mortality risk

Abstract Background Various definitions of very severe (VS) tricuspid regurgitation (TR) have been proposed based on the effective regurgitant orifice area (EROA) or tricuspid coaptation gap (TCG). Because of the inherent limitations associated with the EROA, we hypothesized that the TCG would be more suitable for defining VSTR and predicting outcomes. Purpose To compare EROA and TCG for outcome prediction in patients with severe TR. Methods In this French multicentre retrospective study, we included 606 patients with ≥ moderate-to-severe isolated TR (without structural valve disease or an overt cardiac cause) according to the recommendations of the European Association of Cardiovascular Imaging. Patients were further stratified into VSTR according to the EROA (≥60 mm²) and then according to the TCG (≥10 mm). The primary endpoint was all-cause mortality and the secondary endpoint was cardiovascular mortality. Results The relationship between the EROA and TCG was poor (R²=0.21), especially when the size of the defect was large. Four-year survival was comparable between patients with an EROA <60 mm² vs. ≥ 60 mm² (67±3% vs. 64±4%, p=0.64), even after adjustment, for all-cause (p=0.72) and cardiovascular mortality (p=0.18). A TCG ≥10 mm was associated with lower four-year survival than a TCG <10 mm (53±7% vs. 69±3%, p<0.001). After adjustment for covariates, including age, comorbidity, right heart failure, dose of diuretics, and right ventricular dysfunction, a TCG ≥10 mm remained independently associated with higher all-cause mortality (adjusted HR[95%CI]=1.46[1.15-2.18], p=0.015) and cardiovascular mortality (adjusted HR[95%CI]=1.95[1.22-3.14], p <0.001), whereas an EROA ≥60 mm² was not associated with all-cause or cardiovascular mortality (adjusted HR[95%CI]:1.07[0.75-1.51], p=0.720, and adjusted HR[95%CI]:1.35[0.87-2.09], p=0.176, respectively). Conclusion The correlation between the TCG and EROA is weak and decreases with increasing defect size. A TCG ≥10mm is associated with increased all-cause and cardiovascular mortality and should be used to define VSTR in isolated TR.Correlation between EROA and TCGEvent free survival curves

Diastolic dysfunction is associated with cardiac decompensation after transjugular intrahepatic portosystemic shunt in patients with liver cirrhosis.

About 20% of patients develop cardiac decompensation within the first year after transjugular intrahepatic portosystemic shunt (TIPS) insertion. However, risk factors for cardiac decompensation remain poorly defined. We aimed to evaluate predictors of cardiac decompensation after TIPS insertion in a large, well-defined cohort of patients with liver cirrhosis. 234 cirrhotic patients who received a TIPS at Hannover Medical School were retrospectively followed up for one year to assess the incidence of cardiac decompensation. Echocardiographic parameters and established diagnostic criteria for cardiac impairment (e.g. by the American Society of Echocardiography/ European Association of Cardiovascular Imaging (ASE/EACVI)) were investigated for an association with cardiac decompensation in a competing risk analysis. Survival was analyzed using a multivariable cox regression analysis adjusting for Freiburg index of post-TIPS survival. Predominant TIPS indication was ascites (83%). Median age was 59years, median MELD-score 12% and 58% were male. Overall, 41 patients (18%) developed cardiac decompensation within one year after TIPS insertion. Diastolic dysfunction according to the ASE/EACVI was diagnosed in 26% of patients at baseline and was linked to a significantly higher risk for cardiac decompensation (p=0.025) after TIPS. When investigating individual echocardiographic baseline parameters, only pathological E/A (<0.8 or >2) was identified as a risk factor for cardiac decompensation (p=0.015). Mortality and liver transplantation (n=50) were significantly higher among patients who developed cardiac decompensation (HR=5.29, p<0.001) as well as in patients with a pathological E/A (HR=2.34, p=0.006). Cardiac high-risk status (44% of patients) was strongly linked to cardiac decompensation (HR=2.93, p=0.002) and mortality (HR=2.24, p=0.012). Cardiac decompensation after TIPS is a frequent and important complication and is associated with reduced survival. American Society of Echocardiography/EACVI criteria and E/A seem to be the best parameters to predict the cardiac risk in cirrhotic patients undergoing TIPS insertion.

Imaging in patients with cardiovascular implantable electronic devices: part 2-imaging after device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC.

Cardiac implantable electronic devices (CIEDs) improve quality of life and prolong survival, but there are additional considerations for cardiovascular imaging after implantation-both for standard indications and for diagnosing and guiding management of device-related complications. This clinical consensus statement (part 2) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients after implantation of conventional pacemakers, cardioverter defibrillators, and cardiac resynchronization therapy (CRT) devices. The document summarizes the existing evidence regarding the role and optimal use of various cardiac imaging modalities in patients with suspected CIED-related complications and also discusses CRT optimization, the safety of magnetic resonance imaging in CIED carriers, and describes the role of chest radiography in assessing CIED type, position, and complications. The role of imaging before and during CIED implantation is discussed in a companion document (part 1).

Imaging in patients with cardiovascular implantable electronic devices: part 1-imaging before and during device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC.

More than 500 000 cardiovascular implantable electronic devices (CIEDs) are implanted in the European Society of Cardiology countries each year. The role of cardiovascular imaging in patients being considered for CIED is distinctly different from imaging in CIED recipients. In the former group, imaging can help identify specific or potentially reversible causes of heart block, the underlying tissue characteristics associated with malignant arrhythmias, and the mechanical consequences of conduction delays and can also aid challenging lead placements. On the other hand, cardiovascular imaging is required in CIED recipients for standard indications and to assess the response to device implantation, to diagnose immediate and delayed complications after implantation, and to guide device optimization. The present clinical consensus statement (Part 1) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients undergoing implantation of conventional pacemakers, cardioverter defibrillators, and resynchronization therapy devices. The document summarizes the existing evidence regarding the use of imaging in patient selection and during the implantation procedure and also underlines gaps in evidence in the field. The role of imaging after CIED implantation is discussed in the second document (Part 2).

The clinical use of stress echocardiography in chronic coronary syndromes and beyond coronary artery disease: a clinical consensus statement from the European Association of Cardiovascular Imaging of the ESC.

Since the 2009 publication of the stress echocardiography expert consensus of the European Association of Echocardiography, and after the 2016 advice of the American Society of Echocardiography-European Association of Cardiovascular Imaging for applications beyond coronary artery disease, new information has become available regarding stress echo. Until recently, the assessment of regional wall motion abnormality was the only universally practiced step of stress echo. In the state-of-the-art ABCDE protocol, regional wall motion abnormality remains the main step A, but at the same time, regional perfusion using ultrasound-contrast agents may be assessed. Diastolic function and pulmonary B-lines are assessed in step B; left ventricular contractile and preload reserve with volumetric echocardiography in step C; Doppler-based coronary flow velocity reserve in the left anterior descending coronary artery in step D; and ECG-based heart rate reserve in non-imaging step E. These five biomarkers converge, conceptually and methodologically, in the ABCDE protocol allowing comprehensive risk stratification of the vulnerable patient with chronic coronary syndromes. The present document summarizes current practice guidelines recommendations and training requirements and harmonizes the clinical guidelines of the European Society of Cardiology in many diverse cardiac conditions, from chronic coronary syndromes to valvular heart disease. The continuous refinement of imaging technology and the diffusion of ultrasound-contrast agents improve image quality, feasibility, and reader accuracy in assessing wall motion and perfusion, left ventricular volumes, and coronary flow velocity. Carotid imaging detects pre-obstructive atherosclerosis and improves risk prediction similarly to coronary atherosclerosis. The revolutionary impact of artificial intelligence on echocardiographic image acquisition and analysis makes stress echo more operator-independent and objective. Stress echo has unique features of low cost, versatility, and universal availability. It does not need ionizing radiation exposure and has near-zero carbon dioxide emissions. Stress echo is a convenient and sustainable choice for functional testing within and beyond coronary artery disease.

Competency-based cardiac imaging for patient-centred care. A statement of the European Society of Cardiology (ESC). With the contribution of the European Association of Cardiovascular Imaging (EACVI), and the support of the Association of Cardiovascular Nursing & Allied Professions (ACNAP), the Association for Acute CardioVascular Care (ACVC), the European Association of Preventive Cardiology (EAPC), the European Association of Percutaneous Cardiovascular Interventions

Imaging plays an integral role in all aspects of managing heart disease and cardiac imaging is a core competency of cardiologists. The adequate delivery of cardiac imaging services requires expertise in both imaging methodology-with specific adaptations to imaging of the heart-as well as intricate knowledge of heart disease. The European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging have developed and implemented a successful education and certification programme for all cardiac imaging modalities. This programme equips cardiologists to provide high quality competency-based cardiac imaging services ensuring they are adequately trained and competent in the entire process of cardiac imaging, from the clinical indication via selecting the best imaging test to answer the clinical question, to image acquisition, analysis, interpretation, storage, repository, and results dissemination. This statement emphasizes the need for competency-based cardiac imaging delivery which is key to optimal, effective and efficient, patient care.