AIMS: This study investigated the incremental prognostic value of cardiovascular magnetic resonance (CMR)-derived extracellular volume fraction (ECV), a marker of diffuse interstitial fibrosis, beyond late gadolinium enh...AIMS: This study investigated the incremental prognostic value of cardiovascular magnetic resonance (CMR)-derived extracellular volume fraction (ECV), a marker of diffuse interstitial fibrosis, beyond late gadolinium enhancement (LGE) in hypertrophic cardiomyopathy (HCM). METHODS AND RESULTS: We analysed 990 consecutive HCM patients (median age 58 years, male 68.3%) who underwent CMR between 2012 and 2024. LGE and global ECV were quantified, and their associations with the primary endpoint of HCM-related events-a composite of sudden cardiac death (SCD) events, heart failure (HF) events, and HCM-related death-were assessed. During a median follow-up of 3.2 years, 64 (6.5%) patients experienced the primary endpoint. While LGE (median 7.1%, IQR 2.3-16.9%) and ECV (median 29.0%, IQR 26.6-32.0%) were moderately correlated (R = 0.604, P < 0.001), both were significantly associated with increased risk of the primary endpoint and individual outcomes of SCD and HF events, and optimal cutoffs were determined as LGE ≥ 27% and ECV ≥ 35%. Patients with ECV ≥ 35% had more symptoms, a more severe phenotype with greater systolic and diastolic dysfunction, and more pathogenic gene variants. Notably, ECV remained a significant predictor of the primary endpoint (adjusted HR 1.08, 95% CI 1.02-1.15, per 1%) after adjustment for key disease variables, including left ventricular ejection fraction and LGE. Elevated ECV effectively identified high-risk individuals even among lower-risk subgroups, including those with low LGE burden. CONCLUSION: Increased ECV is an independent predictor of HCM-related outcomes. ECV may serve as a novel imaging biomarker to refine risk stratification in HCM patients who do not meet traditional LGE-based high-risk criteria.
BACKGROUND: Multiple VA-ECMO studies have recently reported that early hyperoxia is associated with increased mortality, yet the underlying mechanism is unclear. As prior analyses did not account for native cardiac outpu...BACKGROUND: Multiple VA-ECMO studies have recently reported that early hyperoxia is associated with increased mortality, yet the underlying mechanism is unclear. As prior analyses did not account for native cardiac output or fraction of delivered oxygen, it remains unknown whether hyperoxia is directly injurious or primarily a surrogate of poor intrinsic cardiac function and proximal mixing. OBJECTIVES: This study aims to evaluate whether hyperoxia is an independent predictor of mortality in VA-ECMO patients or whether it primarily reflects impaired native cardiac function. METHODS: We conducted a single-center retrospective cohort study of 227 VA-ECMO patients to evaluate the relationship between hyperoxia and ICU mortality, accounting for native cardiac index using multivariable regression and principal component analysis. Average PaO2 and cardiac index were analyzed as continuous variables. RESULTS: Decreased cardiac index was the strongest independent predictor of ICU mortality in a multivariable regression (OR 0.22; 95% CI 0.06-0.70; p = 0.018). After adjusting for native cardiac index and utilization of advanced therapies (i.e., heart transplant or LVAD), the association between hyperoxia and mortality became insignificant. Average PaO2 and cardiac index were strongly inversely collinear (Variance Inflation Factor (VIF) = 7.2 and 11.5, respectively), with their interaction term yielding a VIF of 20.3. Non-survivors and survivors who received advanced therapies share similar PC1 score distributions (a weighted composite of average PaO2 and cardiac index) and impaired hemodynamic profiles, including reduced ejection fraction, pulse pressures, and oxygen delivery indices. CONCLUSIONS: The association between early hyperoxia and mortality in VA-ECMO is primarily driven by underlying cardiac failure rather than direct oxygen toxicity. The availability of advanced therapies further modifies this relationship, underscoring the need to account for both native cardiac output and heart replacement strategies when evaluating optimal PaO2 targets and the independent effect of hyperoxia on VA-ECMO outcomes.
Neyazi M, Bremer JP, Brederecke J
… +9 more, Knorr MS, Seum F, Reinbold C, Gross S, Csengeri D, Blankenberg S, Dörr M, Vollmer M, Bonin-Schnabel R
Eur Heart J Digit Health
· 2026 Jul · PMID 42396383
·
Full text
AIMS: Effective heart failure (HF) prevention requires early identification of high-risk individuals, yet population-wide stratification remains difficult. We evaluated whether deep learning using single-lead (lead I) el...AIMS: Effective heart failure (HF) prevention requires early identification of high-risk individuals, yet population-wide stratification remains difficult. We evaluated whether deep learning using single-lead (lead I) electrocardiograms (ECGs), obtainable from medical systems and wearables, enables population-scale risk assessment. We developed AI-HF to estimate incident clinical HF risk using UK Biobank (UKB) data, validating in the prospective SHIP-START and SHIP-TREND cohorts. METHODS AND RESULTS: The analysis included 31 740 UKB participants (median age 64, 5.2 year follow-up, 243 events), 3025 SHIP-START participants (age 50, 15 year follow-up, 166 events), and 1342 SHIP-TREND participants (age 51, 9 year follow-up, 84 events). Participants with prevalent HF were excluded. Performance was evaluated at a harmonized 5-year prediction horizon. C-indices for incident clinical HF were 0.693 [95% confidence interval (CI) 0.654-0.732] in UKB, 0.715 (0.652-0.777) in SHIP-START, and 0.791 (0.749-0.833) in SHIP-TREND. Hazard ratios per standard deviation increase in AI-HF output were 1.67 (1.56-1.79), 1.43 (1.25-1.65), and 1.46 (1.34-1.59), respectively (all < 0.001). Adding biometric variables improved discrimination modestly (C-indices: 0.714, 0.718, and 0.77). CONCLUSION: Across cohorts, AI-HF identified individuals at elevated 5-year incident clinical HF risk using single-lead ECGs. Given the ubiquity of wearables, this method may enable population-scale assessment to support targeted prevention and early intervention.
Eur Heart J Digit Health
· 2026 Jul · PMID 42396382
·
Full text
'Artificial intelligence' (AI), as a blanket term, covers many advanced computing techniques that employ divergent methodologies for a wide array of functions. It is too late to affect general usage of the term without q...'Artificial intelligence' (AI), as a blanket term, covers many advanced computing techniques that employ divergent methodologies for a wide array of functions. It is too late to affect general usage of the term without qualification-although it is a misnomer-but perhaps not too late to argue for the preferential use of more specific and realistic terminologies when discussing useful applications in science and medicine. Large language models are statistical tools for predicting text; machine learning algorithms are programs that discern patterns from data; and neural networks are mathematical models that predict outputs from inputs. In all cases, the software is unaware of what it is doing or why. The real intelligence is human, exemplified by the expertize of the engineers who designed any particular system, and by the scepticism, realism and vision of those who interpret and apply its outputs. Users may suspend their incredulity if large language models that are not sentient creatures are programmed to answer questions in the first person, since that encourages anthropomorphism. Perhaps we need a new word-which could be '-to emphasize the dangers of interacting uncritically with inanimate software programs while overtly or subconsciously ascribing them human cognitive powers. Implementing high standards when applying new computing tools in clinical research and practice should start with the avoidance of inappropriate language that degrades our thinking.
Eur Heart J Digit Health
· 2026 Jul · PMID 42396381
·
Full text
Graphical AbstractFor image description, please refer to the figure legend and surrounding text.Graphical AbstractFor image description, please refer to the figure legend and surrounding text.
Riehle L, Fouad M, Hott M
… +11 more, Heil E, Lee CB, Schoenrath F, Vungarala S, Johnson B, Olson L, Goetz A, Barata F, Cummins N, Hindricks G, Hohendanner F
Eur Heart J Digit Health
· 2026 Jul · PMID 42396380
·
Full text
AIMS: Monitoring pulmonary congestion in chronic heart failure (HF) reduces decompensation and hospitalization, but conventional methods such as weight and symptom tracking are often unreliable. As fluid accumulation aff...AIMS: Monitoring pulmonary congestion in chronic heart failure (HF) reduces decompensation and hospitalization, but conventional methods such as weight and symptom tracking are often unreliable. As fluid accumulation affects the lungs and vocal tract, subtle voice alterations may serve as a non-invasive signal for early detection of worsening HF. METHODS AND RESULTS: The Voice Analysis for Monitoring Patients with HF trial (VAMP-HF, NCT06566911) prospectively enrolled 104 patients hospitalized with acute decompensated HF (ADHF) across two academic centres in the USA and Germany. Daily voice recordings were collected from admission to discharge, with breathing features extracted from speech and acoustic features from sustained vowels. A machine-learning model was trained to classify recordings as admission-phase vs. discharge-phase using leave-one-patient-out. Patients with clinical deterioration, insufficient audio quality, or short length of stay were excluded. Seventy-nine patients were included in the final dataset. The model classified admission and discharge with an -score of 0.83 (95% CI: 0.77-0.90; AUC = 0.90). In patients with higher audio volume ( = 54), performance reached 0.89 (95% CI: 0.82-0.94; AUC = 0.91). When applied to intermediate hospitalization days, model-predicted scores showed progressive increases from admission towards discharge. Performance remained robust irrespective of significant weight loss during hospitalization. CONCLUSION: In this pilot study, structured voice and breathing analysis discriminated hospitalization phase from admission through discharge in patients with ADHF. This non-invasive approach captured progressive changes during the hospital course and warrants further investigation with concurrent objective congestion markers to establish physiological specificity.
AlMejbel HA, AlAhmed MA, Alharbi AM
… +2 more, Ali SM, Alansari MJ
Eur Heart J Case Rep
· 2026 Jul · PMID 42394726
·
Full text
BACKGROUND: Nonbacterial thrombotic endocarditis (NBTE) is a rare cardiac manifestation of antiphospholipid syndrome (APS) and may also occur in patients with malignancy. It can mimic infective endocarditis or rheumatic...BACKGROUND: Nonbacterial thrombotic endocarditis (NBTE) is a rare cardiac manifestation of antiphospholipid syndrome (APS) and may also occur in patients with malignancy. It can mimic infective endocarditis or rheumatic mitral valve disease and often results in valvular disease and embolic complications. CASE SUMMARY: A 39-year-old man with a 10-year history of primary APS presented with acute decompensated heart failure and left-sided weakness. Clinical examination revealed signs of biventricular failure, mid-diastolic and systolic murmurs, and neurological deficits. Transthoracic echocardiography (TTE) revealed severe mitral stenosis, large mitral valve masses, severe tricuspid regurgitation, and pulmonary hypertension. Brain magnetic resonance imaging (MRI) showed a lacunar infarct. Three sets of blood cultures were negative. Transoesophageal echocardiography (TEE) revealed large mobile masses on the mitral valve leaflets. The differential diagnosis included infective endocarditis and NBTE. In the setting of APS and the absence of fever, along with persistently negative blood cultures, NBTE was strongly suspected. Given the presence of severe obstructive mitral stenosis and a life expectancy exceeding one year, the management plan included valvular intervention in collaboration with a multidisciplinary team, alongside supportive therapy and anticoagulation. However, the patient declined surgical intervention and was therefore managed conservatively with optimized medical therapy and anticoagulation. On follow-up, the patient demonstrated clinical improvement with corresponding improvement in echocardiographic parameters. DISCUSSION: NBTE should be considered in APS patients presenting with cardiac murmurs and embolic events. TTE is essential for diagnosis. This case underscores the importance of prompt identification and a multidisciplinary approach.
Ikenaga T, Nozoe M, Mannoji H
… +2 more, Suematsu N, Kubota T
Eur Heart J Case Rep
· 2026 Jul · PMID 42394724
·
Full text
BACKGROUND: The superior vena cava (SVC) is a well-recognized non-pulmonary vein (PV) focus in atrial fibrillation (AF); however, intra-SVC re-entrant atrial tachycardia (AT) is extremely rare. CASE SUMMARY: An 83-year-o...BACKGROUND: The superior vena cava (SVC) is a well-recognized non-pulmonary vein (PV) focus in atrial fibrillation (AF); however, intra-SVC re-entrant atrial tachycardia (AT) is extremely rare. CASE SUMMARY: An 83-year-old woman with a history of PV isolation using radiofrequency ablation 1 year earlier was referred for a second ablation due to recurrent AT. Activation mapping of the AT demonstrated a re-entrant circuit involving the left atrial (LA) posterior wall. Because bilateral PVs were reconnected, pulsed-field ablation (PFA), including PV re-isolation and LA posterior wall isolation, was performed using a circular multi-electrode array PFA catheter. The initial PFA application did not terminate the tachycardia; however, the arrhythmia transitioned to a different AT. High-resolution mapping revealed a re-entrant circuit confined within the SVC sleeves, characterized by transverse re-entrant propagation. Entrainment pacing confirmed intra-SVC re-entry. Circumferential PFA was delivered to the SVC during sinus rhythm, achieving SVC isolation without sinus node dysfunction or phrenic nerve palsy. DISCUSSION: This case demonstrates effective management of intra-SVC re-entrant AT using a circular multi-electrode PFA catheter. High-resolution mapping identified a rare re-entrant circuit confined to the SVC. Owing to its tissue selectivity, PFA enables safe and effective SVC isolation while minimizing the risk of phrenic nerve injury.
Eur Heart J Case Rep
· 2026 Jul · PMID 42394723
·
Full text
BACKGROUND: Right ventricular (RV) pacing may impair left ventricular function through electromechanical dyssynchrony. Although physiologic pacing is recommended when high ventricular pacing burden is anticipated, many e...BACKGROUND: Right ventricular (RV) pacing may impair left ventricular function through electromechanical dyssynchrony. Although physiologic pacing is recommended when high ventricular pacing burden is anticipated, many elderly patients with legacy dual-chamber pacemakers may not be good candidates for pacemaker upgrades and undergo programming optimization instead. The acute effects of transitioning from intrinsic left bundle branch block (LBBB) to RV-paced activation remain incompletely understood. CASE SUMMARY: An 85-year-old man with dilated cardiomyopathy, intrinsic LBBB, progressive renal dysfunction, and dual-chamber pacemaker with long programmed atrioventricular delay and <1% RV pacing presented with reduced left ventricular ejection fraction (LVEF) and pedal oedema. Electrocardiogram (ECG) showed left bundle branch block (LBBB) with a QRS width of 166 ms. Baseline echocardiography showed marked AV dyssynchrony with shortened mitral filling time (30% of R-R interval) and impaired global longitudinal strain (GLS -11.0%) and an LVEF of 37% by biplane Simpson's. Atrioventricular delay (120 ms) optimization induced RV capture and improved filling time (50% of R-R interval), ventricular velocity-time integrals, and interventricular delay. Despite favourable haemodynamic changes, GLS worsened (-8.3% with increased apical rocking, indicating deteriorated myocardial mechanics). DISCUSSION: Improved diastolic filling, stroke volume, and interventricular delay during RV pacing may occur at the expense of myocardial efficiency. Strain imaging provided incremental insight beyond conventional Doppler indices and may assist pacing optimization in patients with intrinsic conduction disease.
Sanaka KO, Pettersson GB, Unai S
… +12 more, Navia J, Roselli EE, Koprivanac M, Gillinov AM, Witten J, Gordon SM, Shrestha NK, Firth A, Al Zein M, Grimm RA, Griffin BP, Xu B
Eur Heart J Imaging Methods Pract
· 2026 Aug · PMID 42394651
·
Full text
AIMS: Data regarding mitral valve (MV) abscess, a severe complication of infective endocarditis, are limited. This study aimed to describe the clinical, microbiological, echocardiographic, and surgical characteristics of...AIMS: Data regarding mitral valve (MV) abscess, a severe complication of infective endocarditis, are limited. This study aimed to describe the clinical, microbiological, echocardiographic, and surgical characteristics of MV abscess. METHODS AND RESULTS: We conducted a retrospective study of adults (≥18 years) with MV abscess identified from the echocardiographic (October 2010-August 2020) and cardiothoracic surgical databases (April 2002-January 2020) at our centre. Data were obtained from electronic medical records. The primary endpoint was all-cause mortality. A total of 154 patients were included [median age 59 years, interquartile range (IQR): 47-68 years; 45% female], with a follow-up of 296 days (IQR: 6-1825 days). Native valves were affected in 69% of cases. Coagulase-negative Staphylococci (22%) were the most common pathogens, followed by Streptococci (20%), methicillin-resistant staphylococcus (16%), and methicillin-sensitive staphylococcus (14%). Surgery was performed in 146 patients, while 8 were managed conservatively. Bioprosthetic MV replacement was the common surgery (77%), and 27% required a Commando procedure. At surgery, MV abscess (64%) and abscess cavity (32%) were the predominant findings. Surgical classification specified the location and extension of the abscess, with posteromedial annulus being most commonly involved (64%). Mortality was 10% at 30 days, 33% at 1 year, and 71% during the entire follow-up period, without significant differences between native and prosthetic valve groups ( = 0.116). CONCLUSION: MV abscess is a highly morbid condition. Detailed surgical classification supports operative planning and assessment of disease extent. Despite high rates of complex surgery, mortality remains substantial, underscoring the aggressive nature of this condition.
Schneijdenberg JW, Zwaan RR, Chen Y
… +5 more, Bowen DJ, Kauling RM, van Burken G, Bosch JG, van den Bosch AE
Eur Heart J Imaging Methods Pract
· 2026 Aug · PMID 42394650
·
Full text
AIMS: Tetralogy of Fallot (ToF) is a congenital heart disease requiring surgical repair in early childhood. Affected patients cope with severe right ventricle (RV)-related morbidity during adulthood, which is mostly attr...AIMS: Tetralogy of Fallot (ToF) is a congenital heart disease requiring surgical repair in early childhood. Affected patients cope with severe right ventricle (RV)-related morbidity during adulthood, which is mostly attributed to RV remodelling. Improved understanding of RV remodelling patterns is essential for advancements in clinical decision-making and treatment planning. Consequently, a method to enable detailed quantification of directional components of RV function was developed using 3D echocardiography (3DE). METHODS AND RESULTS: From RV-focused 3DE studies of 50 ToF patients and 50 healthy controls, 3D dynamic RV meshes were obtained using commercially available software (TomTec 4D RV-Function). A software tool was developed in-house to decompose RV contraction in longitudinal (LT), radial, and anteroposterior (AP) motion directions. Their respective contributions to RV ejection fraction (EF) were calculated. The AP contraction component was identified as the main contributor in RV function deterioration, showing significant relative reduction in ToF patients compared with healthy controls [38% (31-42) vs. 40% (37-44), = 0.004]. Conversely, the LT direction showed significant relative increase in ToF compared with healthy controls [28% (26-33) vs. 26% (23-31), = 0.009]. CONCLUSION: Our custom software allowed for effective directional decomposition of RV EF, enabling detailed quantification of RV function in patients with ToF. RV function deterioration was primarily due to a decreased contribution of AP wall motion to RV EF, whereas LT contribution showed relative increase. These findings highlight the need for more detailed RV function assessment for improved understanding of RV remodelling.
Bladt M, Keller M, Gawaz M
… +15 more, Schreieck J, Goldschmied A, Amaki M, Matsumoto T, Masaki I, Kuwata S, Kubo S, Hayashida K, Zahr F, Kreidel F, Praz F, Tchétché D, Magunia H, Zdanyte M, Geisler T
Eur Heart J Imaging Methods Pract
· 2026 Aug · PMID 42394649
·
Full text
AIMS: Chronic mitral regurgitation (MR) causes haemodynamic and myocardial changes leading to increased left atrial volume and left ventricular preload and finally eccentric hypertrophy of the left ventricle. The extent...AIMS: Chronic mitral regurgitation (MR) causes haemodynamic and myocardial changes leading to increased left atrial volume and left ventricular preload and finally eccentric hypertrophy of the left ventricle. The extent to which mitral valve transcatheter edge-to-edge repair induced haemodynamic improvements translates into reverse remodelling and clinical benefit remains to be clarified. This project aimed to investigate periprocedural haemodynamic changes during mitral valve transcatheter edge-to-edge repair, their effects on reverse cardiac remodelling, and the associated effects on heart failure-related hospitalization and all-cause mortality. METHODS AND RESULTS: In this retrospective study, 130 patients with severe symptomatic MR underwent transcatheter edge-to-edge repair. Haemodynamic parameters were assessed pre- and immediately post-procedure, and echocardiography was performed at 6-12 months (median 188 days, IQR 26). Clinical follow-up included 1-year heart failure hospitalization and all-cause mortality. Short-term haemodynamic data were available in 86 patients and long-term echocardiographic follow-up in 73, with incomplete datasets excluded from the respective analyses. Mitral valve transcatheter edge-to-edge repair significantly improved cardiac index (+11.37%, < 0.01) and reduced left atrial pressures (-36.97%, < 0.01). Echocardiography demonstrated reduced left ventricular end-diastolic diameter (-2.8 mm, -4.0%, = 0.004) and improved right ventricular function (+5.8%, = 0.019) at follow-up. Patients with improved left ventricular global longitudinal strain had lower mortality and hospitalization rates. CONCLUSION: Mitral valve transcatheter edge-to-edge repair with the PASCAL® system is linked with immediate haemodynamic improvements that may be associated with reverse cardiac remodelling and improved mid-term clinical outcomes. Monitoring acute haemodynamic effects may help predict positive remodelling and outcome effects.
AIM: To describe exercise hemodynamics across cardiac damage stages and evaluate the incremental prognostic impact of cardiac damage stage and exercise-induced pulmonary hypertension (exPHT) in patients with symptomatic...AIM: To describe exercise hemodynamics across cardiac damage stages and evaluate the incremental prognostic impact of cardiac damage stage and exercise-induced pulmonary hypertension (exPHT) in patients with symptomatic moderate aortic stenosis (AS) and asymptomatic severe AS. METHODS AND RESULTS: A total of 436 consecutive patients with ≥moderate AS (74 ± 10 years, 32% women, 56% severe AS) underwent cardiopulmonary exercise testing with echocardiography. The primary endpoint was heart failure (HF) death and HF hospitalizations. Cardiac damage stage was 0 in 93 patients, 1 (LV damage) in 135, 2 (LA/mitral damage) in 135, and 3-4 (pulmonary vasculature/tricuspid or RV damage) in 73. Higher stages were associated with worse exercise capacity and hemodynamics. Over a median follow-up of 37 months, 65 patients met the primary endpoint. After adjustment for age, AS severity, and aortic valve replacement, cardiac damage stage and exPHT were independently associated with HF outcomes (HR per stage increase 1.51 [1.26-1.82]; p < 0.001; exPHT HR 2.36 [1.10-5.07]; p = 0.03). exPHT improved risk stratification in early-stage disease (stages 1-2), conferring an approximately fivefold higher risk of HF events in patients with exPHT (HR 4.45 [1.58-12.59]; p < 0.01). CONCLUSIONS: In patients with ≥moderate AS and discordant symptoms, cardiac damage stage and exPHT independently refined HF risk stratification. ExPHT provides incremental prognostic value in early damage stages (1-2), representing over half of the cohort, supporting a stepwise approach of routine damage staging with selective with exPHT assessment with exercise echocardiography in this subgroup to guide more personalized management and potentially optimize AVR timing.