Cardiac imaging is an ever-evolving area, with imaging parameters and application in constant re-evaluation. This was reflected in many imaging debates and by the increased number of scientific contributions at ESC Congress 2022.
The Danish-NICAD2 study, presented in the Hot Line Sessions, evaluated the role of stress cardiac magnetic resonance (CMR) and PET in patients with coronary lesions of unclear significance on CT.1 The performance of CMR and PET was interchangeable, with very good correlation with the anatomical findings of angiography and a high sensitivity for stenoses of >70%. However, there was modest sensitivity of imaging techniques to predict low fractional flow reserve (FFR), with a discrepancy between these advanced perfusion results and the invasive FFR. Another study with a focus on atherosclerotic complications, the PRE18FFIR study, investigated coronary microcalcification plaque activity in patients with previous MI.2 Although coronary microcalcification plaque activity did not predict coronary events or coronary revascularisation, it was associated with cardiac death/non-fatal MI and all-cause mortality. However, one of the most discussed studies presented this year was REVIVED-BCIS2, which revealed no benefit of revascularisation in patients with severe ischaemic left ventricular (LV) impairment (LV ejection fraction [LVEF] 35%) compared with optimal medical therapy based on evidence of viability in at least four dysfunctional myocardial segments by CMR.3
Artificial intelligence (AI)-supported cardiac imaging continues to make headway. ECHO-NET-RCT showed superiority of AI-LVEF over sonographer assessed-LVEF, whereas AI-ENHANCED found conflicting results of an echo-based AI algorithm to determine the severity of aortic stenosis, mainly due to unexpected high mortality in the low-risk group.4,5
Several sessions highlighted the increasing gap between emerging new knowledge in various heart conditions and established clinical practice, as detailed below.
Imaging in Heart Failure with Preserved Ejection Fraction
The diagnostic criteria of HFpEF remain hotly debated; established as an expert consensus agreement, they remain unconfirmed through prospective validation studies.6,7 Yet, the important advances in treatment with sodium–glucose cotransporter 2 inhibitors (and transthyretin amyloidosis) demand the refinement of diagnostic pathways.
Atrial strain and advanced CMR-derived volumes and deformation indices are superior to conventional parameters for the diagnosis and stratification of patients with HFpEF. Interestingly, native T1 measured in the liver was described as a novel marker of congestion.8–12
Several studies evaluating the impact of long COVID on cardiovascular and pulmonary function were presented. These studies differed in the timing of the evaluation, follow-up, size of the population and methods of evaluation, but, in general, showed a high burden of morphological and functional abnormalities when assessed with CMR.13–16 Echocardiography was mostly normal, except for subclinical abnormalities detected with strain.17
The interest in the ‘neglected valve’ is finally gaining ground due to novel percutaneous approaches. Beyond the methods of quantification of regurgitation, a number of studies reiterated the role of right atrial and ventricular measures, such as strain and functional indices, to further characterise the consequences of tricuspid regurgitation on the right heart and predict outcomes.18–21
The importance of atrial size and function measures is also rising. Atrial strain and 3D calculated volume have been shown to predict the development of AF, stroke and even heart failure in different scenarios, such as after a cerebrovascular event, after coronary artery bypass grafting and in dilated cardiomyopathy or hypertrophic cardiomyopathy.22–26 In addition, atrial strain has shown prognostic value in a number of interventions, such as percutaneous mitral valve repair or aortic valve replacement.6,22,26,27
The discovery of new therapies and the pathophysiological insights presented by numerous studies increasingly guide the need for the translation of cardiac imaging technology from research interests towards established measures of clinical practice, with a direct impact on our final objective: to provide the best possible care for our patients.