搜索结果：JACC. Cardiovascular imaging

Breast arterial calcification (BAC) detected on routine mammography is an emerging marker of cardiovascular risk in women. However, substantial age-related variability limits its clinical interpretability. Age-adjusted nomograms may improve risk stratification and communication. This study aims to determine whether age-adjusted BAC percentiles derived from mammography predict major adverse cardiovascular events (MACE) independent of atherosclerotic cardiovascular disease (ASCVD) risk scores. In this multicenter retrospective cohort study, 21,514 women without known cardiovascular disease and aged &#x2265;40 years (57 &#xb1; 12 years) from sites in the United States and Australia underwent screening mammography and ASCVD risk assessment. BAC was quantified using artificial intelligence (cmAngio research edition, CureMetrix Inc) and expressed as age-adjusted percentiles. The primary outcome was MACE (death, ischemic heart disease, stroke, or heart failure). Associations between BAC percentiles with MACE were adjusted for established cardiovascular risk factors using Cox and competing risk regression methods, and incremental predictive value was evaluated. BAC was present in 22.7% of women, increasing with age (8%: <50 years; 61%: >70 years). During a mean follow-up of 4.7 years, 828 MACE (3.8%) occurred. Each 10-percentile increase in BAC was associated with a 17% relative increase in MACE risk (adjusted HR [aHR]: 1.17 [95% CI: 1.015-1.019]; P < 0.001), independent of conventional risk factors. Associations remained significant for each MACE component in competing risk models (all P < 0.001). Women with low ASCVD risk (80% of cohort) had significantly increased MACE with both BAC percentile less than median (aHR: 1.66 [95% CI: 1.35-2.04], P < 0.001) and more than median (aHR: 2.31 [95% CI: 1.82-2.93], P < 0.001). Women with intermediate and high ASCVD risk had greater MACE when BAC was more than median (intermediate aHR: 1.40 [95% CI: 1.07-1.82], P = 0.01; high aHR: 1.65 [95% CI: 1.24-2.21], P < 0.001). The addition of BAC to ASCVD risk score appropriately up-classified 9% of individuals with MACE and down-classified 3% of individuals without events, resulting in an overall net reclassification index of 5% &#xb1; 1%. The C-statistic for the clinical model improved from 0.67 to 0.71 (&#x394; 0.04 [95% CI: 0.01-0.07]; P = 0.042) with addition of BAC. Age-adjusted BAC independently predicts cardiovascular events beyond traditional ASCVD risk scores and reclassifies low- and intermediate-risk individuals. Integration of BAC into cardiovascular risk assessment frameworks may facilitate early identification of at-risk women.

Patients with a coronary artery calcium (CAC) score >300 on dedicated CAC scoring computed tomography (CT) are at equivalent risk of major adverse cardiac events (MACE) as those with established atherosclerotic cardiovascular disease (ASCVD). The aim of the study was to identify the extent of CAC on CT performed for attenuation correction (CTAC) as part of nuclear myocardial perfusion imaging that equates to secondary prevention. We retrospectively studied 17,901 patients (48% female, age 64 &#xb1; 12 years, body mass index 30 kg/m2 [26-36]) who underwent nuclear myocardial perfusion imaging with CTAC (single photon emission computed tomography/CT or positron emission tomography/CT) at a single center. Prior ASCVD was defined as myocardial infarction (MI), cerebrovascular accident, peripheral artery disease, or prior revascularization. A semiquantitative visually estimated CAC score was obtained by scoring CAC in each coronary artery from 0 (absent) to 3 (severe), yielding a total score of 0 to 12 (zero, mild 1-2, moderate 3-6, and severe &#x2265;7). The primary outcome was the composite of death, MI, or late revascularization. Among 13,852 patients without prior ASCVD (CAC zero 45%, mild 23%, moderate 21%, severe 11%) and 4,049 with ASCVD, 2,006 patients (11%) experienced MACE during a median follow-up of 25 (Q1-Q3: 10-43) months. In multivariable Cox regression, patients with severe calcification had no difference in risk for MACE, MI, or all-cause mortality vs ASCVD patients (P > 0.05). Patients without prior ASCVD but with severe CAC (score &#x2265;7) on CTAC demonstrated a risk for cardiovascular events and mortality comparable to those with known ASCVD, highlighting the need for more aggressive management in this high-risk primary prevention group.

Biatrial myxomas are exceptionally rare; an even more unusual variant is a single tumor that straddles the interatrial septum through the fossa ovalis, forming 2 synchronous masses. A 74-year-old woman undergoing routine echocardiography displayed mobile lesions (3.1 &#xd7; 1.4 cm left, 3.6 &#xd7; 1.7 cm right) arising from a common pedicle traversing the fossa ovalis. Transesophageal echocardiography, cardiac magnetic resonance, and computed tomography confirmed a biatrial myxoma with a continuous stalk crossing the septum. Surgery achieved complete en bloc resection; recovery was uneventful aside from transient sinus bradycardia. This case illustrates the diagnostic value of multimodality imaging in defining a myxoma that bridges the atrium-a configuration predisposing to both systemic and pulmonary embolization-and demonstrates the excellent prognosis with prompt surgical excision. Multimodality imaging guides precise surgical planning. Early complete resection prevents dual-chamber embolic complications.

Cardiovascular magnetic resonance (CMR) is a cornerstone for assessing cardiac function and tissue characterization but is often inaccessible to patients with class III obesity because of the bore size and table weight limits of conventional 1.5-T/3-T systems. Five patients with body mass index &#x2265;40 kg/m2 underwent clinically indicated CMR on a 0.55-T 80-cm wide-bore scanner using prototype cine, parametric mapping, phase-contrast flow, late gadolinium enhancement, and thoracic MR angiography sequences. Diagnostic image quality was achieved in all cases, enabling comprehensive evaluation of ventricular function, myocardial tissue, valvular morphology, and aortic anatomy. Findings guided diagnosis, pharmacotherapy optimization, and procedural planning. Wide-bore 0.55-T CMR enables diagnostic imaging in patients with class III obesity, who are often excluded from conventional MR systems. Mid-field CMR with tailored sequences allows comprehensive cardiac evaluation in this underserved population.

Tumor-associated pulmonary embolism is a rare but potentially fatal cause of cardiac arrest. An 8-year-old girl experienced sudden cardiac arrest and required extracorporeal cardiopulmonary resuscitation (ECPR). Point-of-care ultrasound demonstrated right ventricular dilation with impaired contractility, prompting emergent contrast-enhanced computed tomography (CT). An abdominal tumor and bilateral pulmonary artery occlusion were identified on CT, suggesting tumor-associated pulmonary embolism. Extracorporeal membrane oxygenation support was established; however, the patient developed irreversible hypoxic-ischemic brain injury. A limited biopsy confirmed the diagnosis of Ewing sarcoma. Post-ECPR imaging was crucial in identifying the underlying etiology. This case highlights the importance of comprehensive imaging in cardiac arrest and the ethical challenges of ECPR when cardiac pathology is reversible but the neurological prognosis is poor. Point-of-care ultrasound and CT after ECPR can identify rare reversible causes of cardiac arrest. Tumor-associated pulmonary embolism should be considered in unexplained cases. ECPR decisions require balancing neurological prognosis with the treatability of the underlying pathology.

Three-dimensional transesophageal echocardiography (3D TEE) is the primary imaging guidance tool for mitral transcatheter edge-to-edge repair (M-TEER). DeviceGuide technology is a novel investigational software program using artificial intelligence to automatically track the M-TEER device within the 3D TEE volume and reformat images to guide implantation. DeviceGuide can automatically generate multiplanar-reconstructed images that: 1) maintain target location on 3D-rendered views while imaging device location/orientation, 2) automatically generate two-dimensional orthogonal target views with real-time indicators of device position and trajectory, and 3) continuously generate a consistent two-dimensional image of the device and surrounding tissue. Automatic 3D TEE multiplanar reconstruction reformatting reduces the need for manually reformatting while continuously informing proceduralists about device trajectory, position, and orientation. DeviceGuide artificial intelligence-enhanced imaging software has the potential for improving the safety, efficiency, and efficacy of M-TEER implantation for both routine and anatomically complex cases irrespective of operator experience.

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Interleukin (IL)-1 inhibitors have transformed pericarditis management by controlling inflammation and preventing relapse. Their use around pericardiectomy in patients with fixed constriction remains largely unreported. A 42-year-old man with a long-standing inflammatory pericardial syndrome, consistent with incessant pericarditis, developed right-sided heart failure despite long-term anakinra, prednisone, and colchicine, suggestive of evolution to constrictive pericarditis. Echocardiography and cardiac magnetic resonance showed constrictive physiology with pericardial thickening and late gadolinium enhancement but no active edema, supporting a diagnosis of chronic constrictive pericarditis. After invasive hemodynamics confirmed fixed constriction, he was referred for surgical evaluation. Radical pericardiectomy was performed while IL-1 blockade was continued perioperatively. Pathology confirmed dense fibrosis with patchy chronic inflammation. He recovered fully after gradual tapering of anakinra over 3-months postoperatively. This case illustrates the evolution from acute to incessant to constrictive pericarditis and highlights that IL-1 inhibition alone cannot reverse established fibrotic constriction once remodeling is complete. Recognizing the transition from inflammation to fixed constriction is essential for directing patients toward surgical evaluation. IL-1 inhibition can be continued safely around the time of pericardiectomy to prevent rebound inflammation.

The differential diagnosis of aneurysmal dilation of the ventricular wall includes aneurysm, pseudoaneurysm, and diverticulum. Aneurysm and pseudoaneurysm are associated with myocardial ischemia, whereas diverticulum is a congenital anomaly. These conditions can be differentiated using transthoracic echocardiography, and accurate differentiation is crucial because pseudoaneurysms carry a high risk of rupture and require urgent surgical intervention. We describe 3 cases of left ventricular outpouchings with distinct etiologies and clinical implications. The first case involved a true inferior wall aneurysm with thrombus in a patient presenting with heart failure, which was successfully managed with surgical resection. The second case featured multiple pseudoaneurysms and a ventricular septal defect after anterior myocardial infarction complicated by cardiogenic shock, requiring veno-arterial extracorporeal membrane oxygenation, revascularization, and surgical repair. The third case was an incidental finding of a large inferolateral diverticulum in a minimally symptomatic patient. These cases illustrate the diverse presentations of left ventricular outpouchings and underscore the importance of accurate diagnosis and tailored management strategies.

Fibrillin defects lead to severe cardiovascular complications in Marfan syndrome (MFS), including aortic dilation, dissection, and rupture. To model MFS, zebrafish mutants lacking various fibrillin genes were generated. Among these mutant lines, only fibrillin-3-deficient zebrafish exhibited cardiovascular phenotypes mimicking human disease. Multimodal imaging revealed early cardiac defects, bulbus arteriosus dilation, and valve abnormalities. Transcriptomic analysis identified altered regulation of pathways related to extracellular matrix homeostasis and immune system activation. This zebrafish model, recapitulating key cardiovascular features of MFS, provides a valuable platform to investigate disease mechanisms and identify novel treatment strategies.

Deep learning (DL) continues to advance cardiac image analysis with increasingly sophisticated methodologies. Although convolutional neural networks laid the foundation for DL, emerging methods including graph neural networks, transformers, implicit neural representations, generative adversarial networks, and foundation models enable enhanced anatomical and functional modeling, image generation, and multimodal integration. Graph neural networks enable non-Euclidean data representations that preserve anatomical structure; transformers improve sequence modeling in dynamic imaging; and implicit neural representations introduce continuous spatial representations for more accurate reconstructions. Generative adversarial networks enhance image generation, noise reduction, and cross-modality synthesis adaptation, while foundation models introduce a unified, generalizable framework capable of adapting across diverse imaging tasks. This review discusses these key innovations of DL in cardiac imaging, their implications, and their challenges as well as potential future directions in the field, such as clinical validation trials.

Spontaneous coronary artery dissection (SCAD) and atherosclerosis may appear similar on coronary imaging. A 62-year-old woman with fibromuscular dysplasia, dyslipidemia, and diabetes presented with chest discomfort. Coronary computed tomography angiography suggested left anterior descending artery (LAD) SCAD, and invasive coronary angiography (ICA) showed possible type 3 SCAD. Intracoronary imaging (ICI) was not performed, and she was treated medically. Recurrent chest pain prompted repeat imaging. Follow-up computed tomography angiography suggested persistent LAD SCAD. Repeat ICA revealed high-grade proximal LAD and first diagonal stenoses, confirmed as atherosclerosis on ICI. Percutaneous coronary intervention with 2 drug-eluting stents relieved symptoms. At 5 months, recurrent symptoms from severe LAD stenosis proximal to the stents were treated with drug-eluting stents, and ICA at 8 months showed in-stent restenosis, managed by balloon angioplasty. ICI is essential when type 3 SCAD is suspected and angiography is indeterminate. Stent-edge disease and in-stent restenosis highlight important causes of recurrent symptoms after percutaneous coronary intervention.

Epicardial fat necrosis (EFN) is a rare, self-limiting condition that presents as acute severe chest pain. Symptoms can mimic life-threatening conditions (myocardial infarction, pulmonary embolism, and pericarditis). We present 2 cases of EFN with acute, left-sided pleuritic chest pain without a clear precipitating factor. Blood work revealed elevated D-dimer, C-reactive protein, and normal troponin. Chest computed tomography (CT) scan showed characteristic EFN appearance. They were managed with nonsteroidal anti-inflammatory drugs with clinical and imaging resolution. Our cases illustrate typical examples of EFN in presenting with acute, left-sided pleuritic chest pain. Pathogenesis is unknown; incidence is around 0.26% among patients undergoing chest CT in the emergency department. CT &#xb1; cardiac magnetic resonance imaging are crucial in diagnosing the condition. Management is typically conservative, with pharmacological treatment preferred over surgical excision. EFN is a rare, benign cause of acute chest pain in the emergency department. Diagnosis is typically made with CT and/or cardiac magnetic resonance imaging, and management is generally conservative.

Pregnancy-associated myocardial infarction (PAMI) is a rare but potentially life-threatening condition with significant fetomaternal implications. A 22-year-old primigravida at 27 weeks of gestation was incidentally found to have left ventricular apical akinesia during echocardiographic screening. Cardiac magnetic resonance imaging confirmed an infarct in the territory of the left anterior descending artery, and coronary computed tomography angiography at 80 days after the event showed nonobstructive coronaries, suggesting a healed spontaneous coronary artery dissection or resolved thrombus. The patient was managed medically but experienced fetal demise at 28 weeks of gestation. PAMI differs from myocardial infarction in the general population. Spontaneous coronary artery dissection is the leading cause during pregnancy, followed by atherosclerosis. This case highlights the diagnostic complexity of PAMI and underscores the value of multimodal imaging in pregnant patients presenting with cardiac symptoms. Cardiovascular evaluation in pregnancy is crucial, particularly in resource-limited settings. A high clinical suspicion is key to timely diagnosis and appropriate management to improve maternal and fetal outcomes.

Class III cardiovascular device premarket approval (PMA) studies often fail to fully represent the intended-use population (IUP) owing to low enrollment of racial and ethnic minority subjects and women. The impact of research site selection on this is unknown. In this study, we sought to determine if site characteristics predict enrollment of demographic minority and female participants in coronary stent PMA trials and evaluate if site selection could improve representation of the IUP. We pooled data from 8,859 U.S. participants enrolled in 9 pivotal coronary stent PMA studies (2003-2018) across 196 sites. Site characteristics included U.S. region, surrounding county demographics, teaching status, Veterans Administration affiliation, trial volume, female principal investigator (PI) involvement, and number of acute hospital beds. Multivariable regression identified predictors of minority and female enrollment. Participant-to-prevalence ratios (PPRs) were modeled under varying site selection scenarios. Minority participants (12%; PPR = 0.48) and women (30%; PPR = 0.77) were underrepresented. Minority enrollment varied markedly across sites and was predicted by West and South regions, county minority population, population density, and per-capita income (R2 = 0.50; P < 0.001). Modeling estimated that reallocating enrollment from low to high minority-enrolling sites could normalize Black and Hispanic representation (PPRs &#x2265;0.80) without compromising that of non-Hispanic Whites (PPR = 1.00). Female enrollment showed less variation and was poorly predicted by research site characteristics and site PI gender (non-VA status only; R2 = 0.095; P < 0.001); however there were few female PIs (<6%), limiting correlation. Coronary stent PMA studies do not fully reflect the IUP, owing to marked underrepresentation of minority participants and modest underrepresentation of women. Because minority enrollment is influenced by site characteristics, targeted site selection could improve representation; however, improving female enrollment requires alternative strategies. These insights have implications on the planning and design of future cardiovascular device trials.

Myocardial involvement in tuberculosis is exceptionally rare and may closely mimic cardiac sarcoidosis, particularly when presenting with ventricular arrhythmias. A 47-year-old man from a tuberculosis-endemic region presented with sustained monomorphic ventricular tachycardia and biomarker elevation. Coronary angiography was normal. Multimodal imaging demonstrated extensive inflammatory nonischemic myocardial involvement and mediastinal lymphadenopathy. Initial lymph node biopsy showed nonnecrotizing granulomas, leading to a working diagnosis of probable cardiac sarcoidosis and initiation of corticosteroid therapy. Delayed lymph node culture later identified Mycobacterium tuberculosis, prompting revision of the diagnosis and initiation of antituberculous therapy. Despite microbiologic control, recurrent ventricular tachycardia required antiarrhythmic optimization and catheter ablation. This case highlights the diagnostic overlap between tuberculous myocarditis and cardiac sarcoidosis and underscores the importance of microbiologic confirmation in patients from endemic regions. Tuberculosis should be considered in granulomatous myocarditis with ventricular arrhythmias. Multimodal imaging combined with extracardiac tissue culture may be decisive in establishing the correct diagnosis.

Sinus of Valsalva aneurysm (SOVA) is an infrequent condition commonly affecting the right coronary sinus. It is typically asymptomatic unless it compresses or ruptures into nearby structures. A 52-year-old man presented to the emergency department with clinical features of heart failure. Transthoracic echocardiography revealed a large SOVA with associated aortic regurgitation (AR), right ventricular outflow tract obstruction (RVOTo), and biventricular dysfunction. Given concern for impending rupture and hemodynamic compromise, the patient was transferred to a tertiary center with a dedicated aortic team for surgical repair. This is a case of a right saccular SOVA complicated by severe AR, RVOTo, and biventricular failure. Multimodality imaging is needed to define its anatomic extent and functional effect on neighboring structures. Surgical repair is preferred. Unruptured giant SOVA can cause severe AR and RVOTo, leading to acute heart failure and mimicking myocardial infarction. Multimodality imaging and early referral to a specialized centers are critical for timely surgical management.

Late coronary anastomotic complications after Cabrol composite graft repair for aortic dissection are rare and pose unique revascularization challenges. A 72-year-old man with a prior Cabrol composite mechanical aortic graft presented with progressive exertional angina and dyspnea. Stress imaging showed extensive ischemia. Coronary angiography revealed occlusion of the right Cabrol limb and a severely calcified stenosis at the left coronary anastomosis, jeopardizing global coronary supply. After multidisciplinary planning, high-risk percutaneous coronary intervention was undertaken with standby extracorporeal membrane oxygenation support. Conventional balloon techniques failed to sufficiently modify the lesion. Intravascular ultrasound demonstrated dense circumferential calcification at the anastomotic site. Intravascular lithotripsy enabled partial lesion preparation, permitting successful drug-eluting stent deployment. This case highlights multiple unique interventional challenges in a single-remaining-vessel situation with limited hemodynamic support options. Intravascular imaging and lithotripsy enabled successful high-risk percutaneous coronary intervention of a heavily calcified Cabrol graft.