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Risk stratification of myocarditis is challenging due to variable clinical presentations. Cardiovascular magnetic resonance (CMR) is the primary non-invasive imaging modality to investigate myocarditis while electrocardiograms (ECG) are routinely included in the clinical work-up. The association of ECG parameters with CMR tissue characterisation and their prognostic value were investigated in patients with clinically suspected myocarditis. Consecutive patients with suspected myocarditis who underwent CMR and ECG were analysed. Major adverse cardiovascular event (MACE) included all-cause death, hospitalisation for heart failure, heart transplantation, documented sustained ventricular arrhythmia, or recurrent myocarditis. A total of 587 patients were followed for a median of 3.9 years. A wide QRS-T angle, low voltage and fragmented QRS were significantly associated with late gadolinium enhancement. Further, a wide QRS-T angle, low voltage and prolonged QTc duration were associated with MACE in the univariable analysis. In a multivariable model, late gadolinium enhancement (HR: 1.90, 95%CI: 1.17-3.10; p = 0.010) and the ECG parameters of a low QRS voltage (HR: 1.86, 95%CI: 1.01-3.42; p = 0.046) and QRS-T-angle (HR: 1.01, 95%CI: 1.00-1.01; p = 0.029) remained independently associated with outcome. The cumulative incidence of MACE was incrementally higher when findings of both CMR and ECG were abnormal (p<0.001). In patients with clinically suspected myocarditis, abnormal ECG parameters are associated with abnormal tissue characteristics detected by CMR. Further, ECG and CMR findings have independent prognostic implications for morbidity and mortality. Integrating both exams into clinical decision-making may play a role in risk stratification in this heterogeneous patient population.

Anomalous aortic origin of the coronary artery (AAOCA) is a rare cardiac condition that can lead to ischemia or sudden cardiac death, yet it is often overlooked or falsely classified in routine coronary CT angiography (CCTA). Here, we developed, validated, externally tested, and clinically evaluated a fully automated artificial intelligence (AI)-based tool for detecting and classifying AAOCA in 3D-CCTA images. The discriminatory performance of the different models achieved an AUC ≥ 0.99, with sensitivity and specificity ranging 0.95-0.99 across all internal and external testing datasets. Here, we present an AI-based model that enables fully automated and accurate detection and classification of AAOCA, with the potential for seamless integration into clinical workflows. The tool can deliver real-time alerts for potentially high-risk AAOCA anatomies, while also enabling the analysis of large 3D-CCTA cohorts. This will support a deeper understanding of the risks associated with this rare condition and contribute to improving its future management. Anomalous aortic origin of the coronary artery (AAOCA) is a rare cardiac condition that is often falsely classified in routine coronary CT angiography (CCTA). Here the authors developed an AI-based tool was developed to detect and classify AAOCA in CT images with high accuracy to improve management of this condition.

BackgroundRecent evidence underlined the importance of right (RV) involvement in suspected myocarditis. We aim to analyze the possible incremental prognostic value from RV global longitudinal strain (GLS) by CMR.MethodsPatients referred for CMR, meeting clinical criteria for suspected myocarditis and no other cardiomyopathy were enrolled in a dual-center register cohort study. Ejection fraction (EF), GLS and tissue characteristics were assessed in both ventricles to assess their association to first major adverse cardiovascular events (MACE) including hospitalization for heart failure (HF), ventricular tachycardia (VT), recurrent myocarditis and death.ResultsAmong 659 patients (62.8% male; 48.1 ± 16.1 years), RV GLS was impaired (> − 15.4%) in 144 (21.9%) individuals, of whom 76 (58%), 108 (77.1%), 27 (18.8%) and 40 (32.8%) had impaired right ventricular ejection fraction (RVEF), impaired left ventricular ejection fraction (LVEF), RV late gadolinium enhancement (LGE) or RV edema, respectively. After a median observation time of 3.7 years, 45 (6.8%) patients were hospitalized for HF, 42 (6.4%) patients died, 33 (5%) developed VT and 16 (2.4%) had recurrent myocarditis. Impaired RV GLS was associated with MACE (HR = 1.07, 95% CI 1.04–1.10; p < 0.001), HF hospitalization (HR = 1.17, 95% CI 1.12–1.23; p < 0.001), and death (HR = 1.07, 95% CI 1.02–1.12; p = 0.004), but not with VT and recurrent myocarditis in univariate analysis. RV GLS lost its association with outcomes, when adjusted for RVEF, LVEF, LV GLS and LV LGE extent.ConclusionRV strain is associated with MACE, HF hospitalization and death but has neither independent nor incremental prognostic value after adjustment for RV and LV function and tissue characteristics. Therefore, assessing RV GLS in the setting of myocarditis has only limited value.

Cardiovascular patient-specific phantoms can improve patient care through testing and simulation. However, materials like silicone and 3D-printing polymers differ mechanically from biological tissues. Agilus30 Clear, the primary material for 3D-printed phantoms, is much stiffer, nearly isotropic, and lacks strain-hardening behavior. To overcome these challenges, a novel 3D voxel-printing approach may provide an effective solution. This study aimed to explore the applicability of 3D voxel printing, assess how different parameters (strand structure, density, and orientation) affect mechanical properties, and compare them to established phantom materials and porcine cardiovascular tissues. Progressive uniaxial cyclic tension tests were performed across nine stages, varying strain rates and target strain levels, with elastic modulus calculated for comparison. The goal was to stepwise assess whether the overall material stiffness can be reduced, achieving anisotropy and replicating strain-hardening behavior. In the first step, varying the strand density, the tested samples showed a 0%-60% strain modulus of elasticity of 0.215-0.278 N/mm , representing a 4-5-fold reduction in elastic modulus compared to that of the base material, Agilus30 Clear. In the second step, varying the orientation of the structures had a significant influence on the elastic modulus, which was measured. The 0%-60% modulus of elasticity decreased to 0.161-0.192 N/mm , displaying anisotropic material behavior. In the third step, two strand structures specifically designed to mimic fiber recruitment were tested. These resulted in slightly flatter (more linear) stress-strain curves compared to the non-linear strain-softening behavior observed in Agilus30 Clear. However, they still fell short of replicating the desired non-linear strain-hardening behavior characteristic of fiber recruitment in cardiovascular tissues. The novel 3D voxel-printing material approach resulted in reduced elastic modulus, anisotropic behavior, and strain-hardening properties, providing a much closer representation of the mechanical behavior of porcine cardiovascular tissues compared to other available phantom materials. However, there is still significant potential for optimization through further exploration of fiber recruitment replication.

AimIn the clinical setting of acute myocarditis, existing guidelines recommend refraining from moderate-intensity to high-intensity sports for 3–6 months, yet the extent to which these recommendations are implemented by clinicians and followed by patients remains unclear.MethodsFrom January 2020 to December 2023, consecutive patients with myocarditis according to European Society of Cardiology criteria were prospectively enrolled. Myocarditis was categorised into acute, subacute and non-acute myocarditis. Patients completed a sports questionnaire and sports behaviour was categorised into no sports (NSP), recreational (REC) or competitive sports (COMP).ResultsA total of 165 patients with myocarditis (mean age 50±17 years, 35% women) completed the questionnaire. Overall 73 (44%) patients received sports counselling. A total of 44 (72%) patients engaged in sports (REC+COMP) with acute or subacute myocarditis, received sports counselling with 38 (87%) adhering. Overall COMP patients (all male) received more counselling (11/11; 100%) compared with REC (53/105; 50%) and NSP (9/49; 18%). Of 39 women in the REC group, 14 (36%) received recommendations, whereas of 66 men 39 (59%) received recommendations (p<0.001). Of all patients engaged in sports, 55% received recommendations. Self-reported adherence to recommendations was significantly lower in COMP (73%) compared with REC (92%, p<0.001).ConclusionAlthough only half of the myocarditis patients received counselling regarding sports activity, adherence to these recommendations was generally high but varied by activity level. Women received fewer recommendations overall compared with men. While competitive athletes were counselled more frequently than recreational athletes, they were less likely to adhere to the recommendations.

Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital heart condition with fixed and dynamic stenotic elements, potentially causing ischemia. Invasive coronary angiography under stress is the established method for assessing hemodynamics in AAOCA, yet it is costly, technically intricate, and uncomfortable. Computational fluid dynamics (CFD) simulations offer a noninvasive alternative for patient-specific hemodynamic analysis in AAOCA. This systematic review examines the role of CFD simulations in AAOCA, encompassing patient-specific modeling, noninvasive imaging-based boundary conditions, and flow characteristics. Screening articles using AAOCA and CFD-related terms prior to February 2023 yielded 19 publications, covering 370 patients. Over the past four years, 12 (63%) publications (259 patients) employed dedicated CFD models, whereas 7 (37%) publications (111 patients) used general-purpose CFD models. Dedicated CFD models were validated for fixed stenosis but lacked dynamic component representation. General-purpose CFD models exhibited variability and limitations, with fluid–solid interaction models showing promise. Interest in CFD modeling of AAOCA has surged recently, mainly utilizing dedicated models. However, these models inadequately replicate hemodynamics, necessitating novel CFD approaches to accurately simulate pathophysiological changes in AAOCA under stress conditions.

Objectives Cardiovascular magnetic resonance feature tracking (CMR-FT) is an emerging technique for assessing myocardial strain with valuable diagnostic and prognostic potential. However, the reproducibility of biventricular CMR-FT analysis in a large cardiovascular population has not been assessed. Also, evidence of confounders impacting reader reproducibility for CMR-FT in patients is unknown and currently limits the clinical implementation of this technique. Methods From a dual-center database of patients referred to CMR for suspected myocarditis, 125 patients were randomly selected to undergo biventricular CMR-FT analysis for 2-dimensional systolic and diastolic measures, with additional 3-dimensional analysis for the left ventricle. All image analysis was replicated by a single reader and by a second reader for intra- and inter-reader analysis (Circle Cardiovascular Imaging). Reliability was tested with intraclass correlation (ICC) tests, and the impact of imaging confounders on agreement was assessed through multivariable analysis. Results Left and right ventricular ejection fractions were reduced in 34% and 37% of the patients, respectively. Good to excellent reliability was shown for 2D (all ICC > 0.85) and 3D (all ICC > 0.70) peak strain and early diastolic strain rate for both ventricles in longitudinal orientation as well as circumferential orientations for the left ventricle. An increased slice number improved agreement while the presence of pericardial effusion compromised diastolic strain rate agreement, and arrhythmia compromised right ventricular agreement. Conclusion In a large clinical cohort, we could show CMR-FT yields excellent inter-reader and intra-reader reproducibility. Multi-parametric CMR-FT of the right and left ventricles appears to be a robust tool in cardiovascular patients referred to CMR. Clinical trial registration. ClinicalTrials.gov Identifier: NCT03470571, NCT04774549. Key Points • Cardiovascular magnetic resonance feature tracking (CMR-FT) is an emerging technique to measure myocardial strain in cardiovascular patients referred for CMR; however, the evaluation of its reproducibility in a large cohort has not yet been performed . • In a large clinical cohort, CMR-FT yields excellent inter-reader and intra-reader reproducibility for both left and right ventricular systolic and diastolic parameters . • Arrhythmia and pericardial effusion compromise agreement of select FT parameters, but poor ejection fraction does not .

Objective To create high-resolution, patient-specific 3D coronary artery models aimed at developing digital models and functional phantoms for the testing of cardiac catheterization devices. Methods Using coronary computed tomography angiography (CCTA) and optical coherence tomography (OCT), coronary artery lesions were identified and quantified. Imaging data were fused using a custom-made workflow to create highly accurate digital 3D models. For validation of the workflow, coronary artery phantoms were fabricated using additive manufacturing. An OCT was then conducted on the 3D printed phantom, and the developed workflow was applied to generate a derivative model, which was subsequently compared to the original. Results CCTA and OCT datasets from 15 patients were successfully collected and used to develop patient-specific 3D coronary artery models, including detailed inner shells, calcifications, outer wall structures, and side branches. Of these, 13 out of 15 3D printed phantoms were successfully validated and compared to their corresponding original model. The median vertex deviation of the derivative model was 0.15 (0.14 - 0.17) mm. The median absolute stenosis difference between the derivative model and the original model was 3 (1–5)%AS. Conclusion We present a novel workflow to produce high-resolution patient-specific phantoms of coronary arteries.

Abstract Background The notion that the ‘interarterial’ segment of anomalous aortic origin of a coronary artery (AAOCA) is ‘malignant’ and ‘scissor-like’ compressed between the aorta and pulmonary artery (PA) is debated, owing to the lower pressure in the pulmonary system compared with that in the coronary system. However, data supporting or refuting this belief under stress conditions are lacking. Case summary Three cases of right AAOCA with interarterial/intramural courses (52, 66, and 51 years old) were assessed. Invasively measured fractional flow reserve (FFR) under dobutamine was 0.85, 0.82, and 0.81, respectively. Intravascular ultrasound illustrated lateral vessel compression of the intramural course with a decrease of minimal lumen area (MLA) (i.e. 5.71–3.47 mm2, 5.88–4.00 mm2, and 5.85–4.06 mm2) under stress conditions with heart rates of 130, 140, and 150 b.p.m., respectively. Pulmonary artery pressure (PAP) increased from rest {s/d (m) [systolic/diastolic (mean)] 22/11 (15), 15/2 (5), and 24/6 (14) mmHg} to stress [s/d (m) 47/24 (36), 30/3 (11), and 36/22 (24) mmHg] and remained below aortic peak pressure (blood pressure, BP) rest [s/d (m) 116/64 (91), 94/48 (71), 99/53 and (62) mmHg]; BP stress [s/d (m) 142/63 (80), 123/63 (88), and 86/46 (62) mmHg]; coronary pressure (CoP) rest [s/d (m) 100/59 (80), 80/45 (62), and 83/47 (63) mmHg]; and CoP stress [s/d (m) 95/60 (69),101/54 (72), and 70/32 (50) mmHg]. Conclusion This case series challenges the assumption that the interarterial segment of AAOCA is scissor-like compressed by both the aorta and PA. The decrease in MLA and FFR under stress is due to the aorta’s unidirectional lateral compression on the intramural segment. Additionally, the term ‘malignant’ should not be universally applied to all AAOCA cases with an interarterial course, as not all result in haemodynamic significance.

According to updated Lake-Louise Criteria, impaired regional myocardial function serves as a supportive criterion in diagnosing myocarditis. This study aimed to assess visual regional wall motional abnormalities (RWMA) and novel quantitative regional longitudinal peak strain (RLS) for risk stratification in the clinical setting of myocarditis. In patients undergoing CMR and meeting clinical criteria for suspected myocarditis global longitudinal strain (GLS), late gadolinium enhancement (LGE), RWMA and RLS were assessed in the anterior, septal, inferior, and lateral regions and correlated to the occurrence of major adverse cardiac events (MACE), including heart failure hospitalization, sustained ventricular tachycardia, recurrent myocarditis, and all-cause death. In 690 consecutive patients (age: 48.0 ± 16.0 years; 37.7% female) with suspected myocarditis impaired RLS was correlated with RWMA and LV-GLS but not with the presence of LGE. At median follow up of 3.8 years, MACE occurred in 116 (16.8%) patients. Both, RWMA and RLS in anterior-, septal-, inferior-, and lateral- locations were univariately associated with outcomes (all p < 0.001), but not after adjusting for clinical characteristics and LV-GLS. In the subgroup of patients with normal LV function, RWMA were not predictive of outcomes, whereas septal RLS had incremental and independent prognostic value over clinical characteristics (HRadjusted = 1.132, 95% CI 1.020–1.256; p = 0.020). RWMA and RLS can be used to assess regional impairment of myocardial function in myocarditis but are of limited prognostic value in the overall population. However, in the subgroup of patients with normal LV function, septal RLS represents a distinctive marker of regional LV dysfunction, offering potential for risk-stratification.CI: confidence interval, CMR: cardiac magnetic resonance imaging, HR: hazard ratio, MACE major adverse cardiovascular events