Arsanjani, Reza

Bioprosthetic aortic valve degeneration (BAVD) is a significant clinical concern following both transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). The increasing use of bioprosthetic valves in aortic valve replacement in younger patients and the subsequent rise in cases of BAVD are acknowledged in this review which aims to provide a comprehensive overview of the incidence, diagnosis, predictors, and management of BAVD. Based on a thorough review of the existing literature, this article provides an updated overview of the biological mechanisms underlying valve degeneration, including calcification, structural deterioration, and inflammatory processes and addresses the various risk factors contributing to BAVD, such as patient demographics, comorbidities, and procedural variables. The difficulties in early detection and accurate diagnosis of BAVD are discussed with an emphasis on the need for improved imaging techniques. The incidence and progression of BAVD in patients undergoing TAVR versus SAVR are compared, providing insights into the differences and similarities between the two procedures and procedural impacts on valve longevity. The current strategies for managing BAVD, including re-intervention options of redo surgery and valve-in-valve TAVR, along with emerging treatments are discussed. The controversies in the existing literature are highlighted to offer directions for future investigations to enhance the understanding and management of BAVD.

Abstract Aims The increasing need for diagnostic echocardiography tests presents challenges in preserving the quality and promptness of reports. While Large Language Models (LLMs) have proven effective in summarizing clinical texts, their application in echo remains underexplored. Methods and results Adult echocardiography studies, conducted at the Mayo Clinic from 1 January 2017 to 31 December 2017, were categorized into two groups: development (all Mayo locations except Arizona) and Arizona validation sets. We adapted open-source LLMs (Llama-2, MedAlpaca, Zephyr, and Flan-T5) using In-Context Learning and Quantized Low-Rank Adaptation fine-tuning (FT) for echo report summarization from ‘Findings’ to ‘Impressions.’ Against cardiologist-generated Impressions, the models’ performance was assessed both quantitatively with automatic metrics and qualitatively by cardiologists. The development dataset included 97 506 reports from 71 717 unique patients, predominantly male (55.4%), with an average age of 64.3 ± 15.8 years. EchoGPT, a fine-tuned Llama-2 model, outperformed other models with win rates ranging from 87% to 99% in various automatic metrics, and produced reports comparable to cardiologists in qualitative review (significantly preferred in conciseness (P < 0.001), with no significant preference in completeness, correctness, and clinical utility). Correlations between automatic and human metrics were fair to modest, with the best being RadGraph F1 scores vs. clinical utility (r = 0.42) and automatic metrics showed insensitivity (0–5% drop) to changes in measurement numbers. Conclusion EchoGPT can generate draft reports for human review and approval, helping to streamline the workflow. However, scalable evaluation approaches dedicated to echo reports remains necessary.

The assessment of left atrial strain (LAS) has emerged as an essential component in the evaluation of cardiac function, especially in pathologies such as heart failure and atrial fibrillation. This narrative review aims to outline the available methods for assessing LAS with a major emphasis on speckle-tracking echocardiography techniques. Other imaging modalities, including cardiac magnetic resonance and cardiac computed tomography, also provide important information on LA dynamics but have disadvantages with respect to cost and availability. The current narrative review underlines basic concepts such as the accurate assessment of LAS and discusses the clinical relevance of LAS by pointing out its significant diagnostic and prognostic role in several cardiovascular conditions. The aim of this article is to discuss the current integration of LAS into clinical practice with a view to further improving patient management and treatment strategies.

Abstract Aims Lipoprotein(a) (Lp(a)) levels are known to be mainly genetically determined. However, only scarce data are available on the intra-individual variability of Lp(a) levels across time. Methods and results We included adult patients (≥18 years old) who had baseline and follow-up Lp(a) measurements (between 1997 and 2024) with a minimum of 1 year apart. Patients were categorized into three groups as follows: normal (<30 mg/dL), borderline (30 to 50 mg/dL), and high Lp(a) (≥50 mg/dL). Multivariable logistic regression was conducted to assess the predictors of the intra-individual changes in Lp(a) ≥ 10 mg/dL. A total of 11 669 individuals (median age: 54 years, 60% males) were included in our analysis, with median time between measurements of 4.5 years [interquartile range (IQR): 2.2, 10.6]. The median Lp(a) was 16 mg/dL (IQR: 7, 52) at baseline, compared with 15 mg/dL (IQR: 7, 52) at follow-up. At follow-up, 96.4% of individuals with normal Lp(a) and 89.9% with high Lp(a) remained in their categories, while 51.2% with borderline Lp(a) changed their category. Of the included population, 24.9% had an intra-individual Lp(a) change ≥ 10 mg/dL. Female sex (P < 0.001), history of ASCVD (P = 0.003), statin therapy (P = 0.003), and elevated LDL cholesterol (LDL-C) levels ≥ 100 mg/dL (P < 0.001) were significantly associated with higher odds of intra-individual Lp(a) changes ≥ 10 mg/dL. Conclusion Lipoprotein(a) levels were generally stable over time; however, patients with borderline levels may require more than one Lp(a) measurement, especially if they are females, have a history of ASCVD, have elevated LDL-C levels, or are on statin therapy.

Lipoprotein (a) is a complex lipid molecule that has sparked immense interest in recent years, after studies demonstrated its significant association with several cardiovascular conditions. Lp(a) promotes cardiovascular disease through its combined proatherogenic, pro-inflammatory, and prothrombotic effects. While the measurement of Lp(a) has become widely available, effective methods to reduce its concentration are currently limited. However, emerging data from ongoing clinical trials involving antisense oligonucleotides have indicated promising outcomes in effectively reducing Lp(a) concentrations. This may serve as a potential therapeutic target in the management and prevention of myocardial infarction, calcific aortic stenosis, and cerebrovascular accidents. In contrast, the role of Lp(a) in atrial fibrillation, in-stent restenosis, cardiac allograft vasculopathy, and bioprosthetic aortic valve degeneration remains unclear. This review article aims to thoroughly review the existing literature and provide an updated overview of the evidence surrounding the association of Lp(a) and these cardiovascular diseases. We seek to highlight controversies in the existing literature and offer directions for future investigations to better understand Lp(a)’s precise role in these conditions, while providing a summary of its unique molecular characteristics.

Coronary CT angiography (CCTA) is now endorsed by all major cardiology guidelines for the investigation of chest pain and assessment for coronary artery disease (CAD) in appropriately selected patients. CAD is a leading cause of morbidity and mortality. There is extensive literature to support CCTA diagnostic and prognostic value both for stable and acute symptoms. It enables rapid and cost-effective rule-out of CAD, and permits quantification and characterization of coronary plaque and associated significance. In this comprehensive review, we detail the road traveled as CCTA evolved to include quantitative assessment of plaque stenosis and extent, characterization of plaque characteristics including high-risk features, functional assessment including fractional flow reserve-CT (FFR-CT), and CT perfusion techniques. The state of current guideline recommendations and clinical applications are reviewed, as well as future directions in the rapidly advancing field of CT technology, including photon counting and applications of artificial intelligence (AI).

Athlete’s heart (AH) represents the heart’s remarkable ability to adapt structurally and functionally to prolonged and intensive athletic training. Characterized by increased left ventricular (LV) wall thickness, enlarged cardiac chambers, and augmented cardiac mass, AH typically maintains or enhances systolic and diastolic functions. Despite the positive health implications, these adaptations can obscure the difference between benign physiological changes and early manifestations of cardiac pathologies such as dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), and arrhythmogenic cardiomyopathy (ACM). This article reviews the imaging characteristics of AH across various modalities, emphasizing echocardiography, cardiac magnetic resonance (CMR), and cardiac computed tomography as primary tools for evaluating cardiac function and distinguishing physiological adaptations from pathological conditions. The findings highlight the need for precise diagnostic criteria and advanced imaging techniques to ensure accurate differentiation, preventing misdiagnosis and its associated risks, such as sudden cardiac death (SCD). Understanding these adaptations and employing the appropriate imaging methods are crucial for athletes’ effective management and health optimization.

Background: Conduction abnormality post-transcatheter aortic valve implantation (TAVI) remains clinically significant and usually requires chronic pacing. The effect of right ventricular (RV) pacing post-TAVI on clinical outcomes warrants further studies. Methods: We identified 147 consecutive patients who required chronic RV pacing after a successful TAVI procedure and propensity-matched these patients according to the Society of Thoracic Surgeons (STS) risk score to a control group of patients that did not require RV pacing post-TAVI. We evaluated routine echocardiographic measurements and performed offline speckle-tracking strain analysis for the purpose of this study on transthoracic echocardiographic (TTE) images performed at 9 to 18 months post-TAVI. Results: The final study population comprised 294 patients (pacing group n = 147 and non-pacing group n = 147), with a mean age of 81 ± 7 years, 59% male; median follow-up was 354 days. There were more baseline conduction abnormalities in the pacing group compared to the non-pacing group (56.5% vs. 41.5%. p = 0.01). Eighty-eight patients (61.6%) in the pacing group required RV pacing due to atrioventricular (AV) conduction block post-TAVI. The mean RV pacing burden was 44% in the pacing group. Left ventricular ejection fraction (LVEF) was similar at follow-up in the pacing vs. non-pacing groups (57 ± 13.0%, 59 ± 11% p = 0.31); however, LV global longitudinal strain (−12.7 ± 3.5% vs. −18.8 ± 2.7%, p < 0.0001), LV apical strain (−12.9 ± 5.5% vs. 23.2 ± 9.2%, p < 0.0001), and mid-LV strain (−12.7 ± 4.6% vs. −18.7 ± 3.4%, p < 0.0001) were significantly worse in the pacing vs. non-pacing groups. Conclusions: Chronic RV pacing after the TAVI procedure is associated with subclinical LV systolic dysfunction within 1.5 years of follow-up.

Coarctation of the aorta (CoA) comprises 5–7% of congenital heart disease and can present as an isolated narrowing in the aortic arch just distal to the left subclavian artery or can be associated with cardiac abnormalities such as a bicuspid aortic valve, aortopathy, or ventricular septal defects. With the advances in the medical field, intervention on CoA can either be via surgical repair or endovascular stenting. Echocardiography is the mainstay in diagnosing CoA, with tomographic imaging such as magnetic resonance imaging (MRI) or computed tomography providing supplementary assessment of the aorta, valves, and collateral vessels. We present a case of a young hypertensive male who was noted to have a continuous cardiac murmur with diagnostic Doppler pattern of CoA on echocardiography that normalized soon after percutaneous stenting.

The long-term survivorship of patients diagnosed with cancer has improved due to accelerated detection and rapidly evolving cancer treatment strategies. As such, the evaluation and management of cancer therapy related complications has become increasingly important, including cardiovascular complications. These have been captured under the umbrella term “cardiotoxicity” and include left ventricular dysfunction and heart failure, acute coronary syndromes, valvular abnormalities, pericardial disease, arrhythmia, myocarditis, and vascular complications. These complications add to the burden of cardiovascular disease (CVD) or are risk factors patients with cancer treatment are presenting with. Of note, both pre- and newly developing CVD is of prognostic significance, not only from a cardiovascular perspective but also overall, potentially impacting the level of cancer therapy that is possible. Currently, there are varying recommendations and practices regarding CVD risk assessment and mitigating strategies throughout the cancer continuum. This article provides an overview on this topic, in particular, the role of cardiac imaging in the care of the patient with cancer. Furthermore, it summarizes the current evidence on the spectrum, prevention, and management of chemotherapy-related adverse cardiac effects.