Advanced cardiac imaging techniques such as cardiovascular magnetic resonance (CMR) and positron emission tomography (PET) are widely used in clinical practice in patients with acute myocarditis and chronic inflammatory cardiomyopathies (I-CMP). We aimed to provide a review article with practical recommendations from the European Society of Cardiovascular Radiology (ESCR), in order to guide physicians in the use and interpretation of CMR and PET in clinical practice both for acute myocarditis and follow-up in chronic forms of I-CMP. Advanced cardiac imaging techniques such as cardiovascular magnetic resonance (CMR) and positron emission tomography (PET) are widely used in clinical practice in patients with acute myocarditis and chronic inflammatory cardiomyopathies (I-CMP). I-CMPs are characterised by inflammatory cell infiltration into the myocardium in association with cardiac dysfunction, ventricular remodelling and have both infectious and non-infectious aetiology Fig.  1]. Vir. Vir1]. subepicardial and mid-myocardial wall involvement in acute myocarditis and I-CMP -fluoro-D-glucose , 2: dolor (patient history), 3: tumor , 4: function laesa . Furthermore, it enables a multiparametric assessment that combines the evaluation of myocardial tissue abnormalities, the impairment of the contractile function and the pericardial involvement. The presence of myocardial oedema, hyperaemia, necrosis and/or fibrosis represents the typical features of inflammatory damage and allow to assess the extent and degree of activity of the myocardial injury   as impleThe intrinsic limitations in evaluating the myocardial edema when the T2 SI is diffusely increased can be overcome by the semi-quantitative analysis based on the normalization of myocardial SI to that of the skeletal muscle. A myocardial-to-skeletal muscle T2 signal ratio > 2 may be considered consistent for the presence of edema . New appHyperaemia reflects the increased permeability of the vessels associated to the inflammatory response. The detection of this phenomenon results to be the most difficult and challenging for CMR . AccordiNecrosis, and subsequent fibrosis, represents the irreversible step of myocardial injury induced by the inflammatory cascade and are both associated with alteration of the permeability of the sarcolemma resulting in a myocardial accumulation of gadolinium .LGE imaging has proven to be a valid tool for the detection of such damage, showing a high specificity  through Furthermore, the LGE areas may persist even in the chronic phase, when the inflammatory activity subsides, with possible shrinkage of the areas of enhancement, in relation to scar remodeling phenomena. It should be noted that in the acute phase it is often impossible to say whether LGE is a sign of focal (irreversible/chronic) fibrosis or oedema. In this situation, FDG PET may aid in the diagnostic definition.Myocardial inflammation may lead to regional or global left ventricle (LV) and right ventricle (RV) dysfunction (function laesa) . HoweverHowever, alterations in regional contractility or global systolic function can underlie multiple pathological conditions, not necessarily related to a direct myocardial insult. Therefore, functional abnormalities should be considered as an ancillary criterion for the diagnosis of myocarditis .Pericarditis and myocarditis often coexist, due to the common etiologic agents and overlapping pathophysiological mechanisms. Although pericardial effusion is a common finding in patients with myocarditis, its presence alone is not sufficient for the diagnosis of pericarditis or myo-pericarditis .Acute pericardial inflammation may be depicted by CMR as thickening of pericardial layers in high-resolution fast spin echo (FSE) T1 images, hyperintensity of the pericardial layers on T2-weighted, or pericardial enhancement on ECG-gated Dixon fat-water separation sequences or LGE images .18 F-FDG uptake, which could be focal, diffuse, or focal on diffuse depending on the underlying nature of the disease [18 F-FDG uptake may show a resolution after treatment, thus holding the potential for monitoring treatment response [Typically, areas of active inflammation present with increased  disease . Such arresponse .18 F-FDG PET/CT and EMB from left ventricular posterior wall. Of note, the authors suggested that the best timing of imaging is within 14 days after the onset of clinical symptoms [18 F-FDG-PET/CT in patients with systemic lupus erythematosus [18 F-FDG uptake in those patients with chest pain, dyspnea and/or impairment of left ventricular ejection fraction (LVEF). Similar results were reported by Besenyi et al. [18 F-FDG uptake compared to healthy subjects. Hence, there is a strong rationale to suggest that the presence of areas of increased myocardial 18 F-FDG uptake in symptomatic patients is highly suggestive for active inflammation, as it can be seen in myocarditis.A retrospective study featuring 29 symptomatic patients showed that there is an excellent correlation between symptoms . Moreoveematosus  showed di et al. , wherein18 F-FDG uptake, corresponding to MR alterations  with acute myocarditis have a benign course with full recovery of ventricular function and resolution of myocardial oedema without sequelae  , 71, 72.Most patients with acute myocarditis have a good short-to-midterm clinical evolution with complete resolution of myocardial edema, improvement of LVEF, and reduction of left ventricular mass index (LVMi), being a marker of global myocardial inflammatory infiltration Table . In the Several studies evaluated the prognostic value of CMR surveillance in the long – term follow up in patients with acute myocarditis Table . Chopra Although advantages have been described in the literature regarding the value of CMR in tissue characterization and risk stratification in the surveillance of I-CMP, there is currently no consensus on the use and timing of CMR during I-CMP follow up. Follow up CMR in I-CMP may be considered in patients with adverse cardiac remodeling (increased LVEDV or LVSV index), impaired LVEF (< 50%), extensive reversible myocardial damage or abundant LGE  , 90, 91.Although parametric mapping techniques have further increased the sensitivity of CMR to diagnose myocardial inflammation, the diagnostic accuracy in low-grade or chronic inflammatory disease might be hampered. Therefore, there is still a need for additional imaging markers to further improve diagnostic accuracy and risk stratification in patients with inflammatory myocardial disease.CMR fingerprinting is a technique that allows for rapid and simultaneous acquisition of multiple, fully co-registered parametric maps within a single scan by matching complex signal measurements to a dictionary of simulated signals , 93. It Artificial intelligence (AI) incorporated with machine learning and deep learning algorithms is going to revolutionize medical healthcare and in particular cardiovascular imaging. CMR lends itself to AI applications because it is based on complex image acquisition, reconstruction, segmentation/quantification, as well as image analysis and diagnostic reporting, which can be markedly improved by machine learning applications . First AMachine learning approaches and big data analysis gave rise to another promising field, termed radiomics. Radiomics reflects a conversion of medical images into high-dimensional data and enables the extraction of various features  that go beyond the conventional visual approach . First rFurthermore, alternative imaging modalities such as spectral dual-energy and photon-counting CT could allow early detection of myocardial inflammation in routine clinical practice, where CT is typically performed before CMR. Hybrid imaging using PET, with its ability to detect focal and chronic inflammation, could be specifically incorporated into diagnostic algorithms for myocarditis and could further improve by the development of new tracers , 106. A 18 F-FDG may help in differentiating between acute and chronic i-CMP, thus allowing to choose the most effective therapeutic approach. Scarce data are available on hybrid PET/MR imaging, but combining the information coming from both morphologic and metabolic assessment may yield improved accuracy in selected cases, wherein the diagnosis is not clear.CMR represents an invaluable tool in the diagnostic work-up of acute myocarditis and chronic i-CMP. In some cases, adding


In line with these findings, in a multivariate continuous logistic regression analysis, the GLS and mitral–tricuspid regurgitation volume were the main parameters associated with worse CV outcomes (GLS: OR 0.77 (95%CI 0.65–0.92); mitral–tricuspid regurgitation volume OR 1.09 (95%CI 1.01–1.25)), whereas the radial and circumferential LV global strain and mitral regurgitation volume and tricuspid regurgitation volume were not linked to the CV outcome. Furthermore, in a receiver operating characteristic curve analysis, a GLS cutoff of <7.5% and mitral–tricuspid regurgitation volume > 60 mL were the identified values for the parameters associated with worse CV outcomes. Conclusions: The findings of this pilot study suggest that the GLS and a novel volumetric parameter  are linked to worse CV outcomes in patients with non-ischemic dilated cardiomyopathy. Hence, these promising results warrant further validation in larger studies.Background: The aim of this pilot study was to determine the potential prognostic relevance of novel multidirectional myocardial and volumetric echocardiographic parameters in patients with non-ischemic dilated cardiomyopathy (NIDCM). Methods: Multidirectional myocardial parameters  strain using speckle tracking echocardiography) and a new volumetric parameter  were assessed. The cardiovascular (CV) outcome was a composite of cardiac death and hospitalization for heart failure (HF) at 1 year. Results: Approximately 102 patients were included in this pilot study. The mean LV ejection fraction (LVEF) was 28.4 ± 8.9%. During a follow-up of 1 year, the CV outcome occurred in 39 patients . The LV global longitudinal systolic strain (GLS) and mitral–tricuspid regurgitation volume were the main parameters that were seen to be significantly altered in the comparison of patients with events vs. those without events  7.4 ± 2.7% vs. 10.3 ± 2.6%; mitral–tricuspid regurgitation volume 61.1 ± 20.4 mL vs. 40.9 ± 22.9 mL, respectively;  Dilated cardiomyopathy (DCM) is associated with LV or biventricular dilation and systolic dysfunction in the absence of abnormal loading conditions. This pathology is a frequent cause of HF and heart transplantation. DCM has a long sub-clinical period occurring with or without symptoms and myocardial changes, which increases the chance of a missed early diagnosis ,2. The pPrevious results have shown that DCM is related to a poor prognosis with high mortality in the early and late periods of the disease ,10. Risk2), poor echocardiographic image quality, inflammatory  or infiltrative myocardial disease, tachycardia-induced HF , previous pulmonary embolism, peripartum cardiomyopathy, patients with an intra-cardiac defibrillator or cardiac resynchronization therapy, toxic damage , and being under the age of 18. Ischemic coronary disease was excluded via angiography or computed tomography and was defined as the presence of a luminal reduction of ≥50% in the epicardial vessels [This was a single-center retrospective–prospective study involving 102 patients with NIDCM. The NIDCM diagnosis was defined according to the latest European Society of Cardiology (ESC) document . The exc vessels ,17, and  vessels . Diabete vessels .Before enrollment, all patients underwent a detailed evaluation , a laboratory test, an electrocardiogram (ECG), Holter monitoring, and 2D transthoracic echocardiography. A cardiac MRI was performed to clarify the specific pathology of the myocardium . In addition, patients were referred for genetic testing (next-generation sequencing of 231 genes coding regions related to inherited heart disorders was performed) and consulted by a geneticist. All participants gave written informed consent before enrollment. This study was approved by the local institutional ethics committee.during the first phase, patients were enrolled, examined for the first time, and diagnosed with NIDCM .during the second phase, the early primary outcomes of a total of 102 patients with diagnosed NICDM were evaluated after a 1-year follow-up from diagnosis.This study consisted of two phases: During follow-up, all patients were treated with an optimal HF treatment according to chronic HF guidelines . InformaTwo-dimensional echocardiography was performed using the Philips “EPIQ 7” according to the European Association of Cardiovascular Imaging recommendations and the EACVI/ASE/Industry Task Force consensus documents ,24. The The LV end-systolic and end-diastolic diameters were assessed from a parasternal LV long-axis view, and the volumes were analyzed using the biplane method of disk summation. The LVEF was assessed using Simpson’s biplane method . For theThe 2D STE was used for the measurement of the LV global systolic index  and the longitudinal–circumferential systolic index  .The right-ventricular (RV) volumes were measured from the 4-chamber views. The RV free wall longitudinal strain (RVFWLS) was assessed from the three segments of the lateral wall . The global RV longitudinal strain (GRVLS) was analyzed from six segments of the RV free wall and the interventricular septum .The right-atrial (RA) volume was assessed using the biplane method of disks in the apical 4-chamber view at end-systole. The LA size was analyzed at the end of the LV systole, and the LA volume (LAV) was measured in apical four- and two-chamber views using the disk summation algorithm . The apiThe mitral–tricuspid regurgitation volume was presented as the sum of the mitral and tricuspid regurgitant volumes assessed using the proximal flow convergence method . Three cApproximately 25 patients were randomly selected to evaluate the intraobserver and interobserver variability, which showed a good agreement for the measurement of the LVGLS, with a small bias of 0.6 ± 2.9% and 0.5 ± 3.4%, respectively.p-value of <0.05 was considered statistically significant. Analyses were performed using SPSS version 22 . We divided our study population into two groups according to the presence of early primary outcomes (with or without the early primary outcomes). Student’s t-test was used to compare normally distributed variables and the Mann–Whitney U-test for abnormal. Binary logistic regression analysis was used to determine the potential predictors of early primary outcomes. The receiver operating characteristic (ROC) curve was plotted to evaluate the predictive value of the echocardiographic parameters to prognosticate early primary outcomes in patients with NIDCM. The cut-off value of the predictive model was defined as the point that yielded the maximum sum of sensitivity and specificity (The results were shown as mean ± standard deviation (SD) or as absolute numbers and percentages. A cificity .p > 0.05). There were no statistically significant differences in the main risk factors  between groups (p > 0.05). The presence of ventricular tachycardia was more common in the study group with early primary outcomes than in the group without . There was no statistically significant difference in atrial fibrillation (p > 0.005). During the first contact, the indicated drugs were usually used for arterial hypertension, alone or in combination therapy. The presence of early primary outcomes was not related to pathogenic variants in DCM. However, a large proportion of patients in this group refused genetic testing. Most of the patients had no stenosis in their coronary arteries. There was a statistically significant difference in brain natriuretic peptide concentrations between groups (p = 0.006). The early primary outcomes were determined in 39 patients .A total of 102 patients with NIDCM formed this study group, and the baseline clinical characteristics are summarized in p = 0.022), the LV end-diastolic diameter index , and the LA volume index . The higher mitral–tricuspid regurgitation volume and worse LV GLS were found in the group with early primary outcomes . The LV GRS and LV GCS did not correlate with a worse prognosis. The LASr function was worse in the study group with events (p < 0.05). The GSI and longitudinal–circumferential systolic index were reduced in both study groups; however, there was no statistically significant difference between these groups.The data from the cardiac 2D echocardiography are shown in p < 0.05).Only patients with an LVEF < 40% were included in the univariate and multivariate logistic regression analysis to determine the potential predictors of adverse events. The results in According to the ROC analysis, patients with NIDCM with an LV GLS below −7.5% had a higher risk of primary adverse events than patients with an LV GLS > −7.5% (sensitivity of 85% and specificity of 84%). The cut-off value for the mitral–tricuspid regurgitation volume for the detection of a worse prognosis was 60 mL, with a sensitivity of 85% and a specificity of 87% .In this study, we evaluated the early primary outcomes of NIDCM patients with moderate-to-severe LV systolic dysfunction according to the 2D STE parameters and morphometrics of both the atria and ventricles. LV GLS and mitral–tricuspid regurgitation volume were the main independent prognostic factors to predict at least one of the following outcomes: cardiac death or hospitalization for WHF at 1 year. Patients with an LV GLS < −7.5% and mitral–tricuspid regurgitation volume values > 60 mL were at maximal risk for early adverse events.The determination of the prognostic factors in HF plays a significant role in clinical treatment decisions and helps us to find the most suitable parameters to evaluate the clinical condition in the follow-up phase. Cardiac imaging methods such as cardiac magnetic resonance (CMR) or echocardiography can carefully assess the myocardial structure and function and have an important significance in the prognostic evaluation of patients with DCM . As CMR There are previous studies that have analyzed prognostic factors in DCM. In one large Swedish HF registry, the same primary outcomes were analyzed as in our study . It was The results of many studies have shown that the LVEF is related to the prognosis of HF. A significant reduction in LVEF is associated with an increased risk of cardiovascular or all-cause mortality, HF hospitalization, or heart transplantation ,29,30,31In DCM, functional mitral and tricuspid regurgitation are related to insufficient leaflet coaptation. The quantitative evaluation of the regurgitation severity can add important value to a patient’s risk stratification because the lesion severity is related to the outcomes ,37. The For many years, the focus has been on the evaluation of the LV, while the RV has been neglected. Advances in cardiac imaging have enabled a better evaluation of the RV, highlighting the importance of biventricular evaluation in DCM patients. The adverse remodeling of the RV has an important role in HF development, and RV systolic dysfunction is more common in NIDCM than in ischemic DCM . PreviouThe assessment of whole-heart myocardial mechanics and morphometrics revealed that the mitral–tricuspid regurgitation volume, together with the LV GLS, can add prognostic information to the evaluation of patients in the early period of DCM, after prescribed optimal HF treatment. To prove these results, it is necessary to repeat the study or expand the sample size as, with larger cohorts, a stronger association with whole-myocardial mechanics could be detected.This study has some limitations. This is a single-center result and do not necessarily represent all patients with NIDCM. Given the small sample size of the study, a further, larger study should be used to validate the findings of this study.The findings of this pilot study suggest that the GLS and a novel volumetric parameter  are linked to worse CV outcomes in patients with non-ischemic dilated cardiomyopathy. Hence, these promising results warrant further validation in larger studies.


Chronic total occlusion (CTO) of the right coronary artery (RCA) is common in patients with coronary artery disease. Although revascularization techniques and success rates have improved significantly in recent years, there are still no studies investigating possible effects of successful recanalization of RCA CTO on the right-ventricular (RV) function. With this study, we aimed to evaluate RV function after recanalization of the RCA by two-dimensional transthoracic echocardiography (2DE) and additional two-dimensional speckle-tracking echocardiography (2DSTE).p < 0.001 and baseline RV global strain − 15.9 [− 6.0 to − 25.7] % vs. − 17.9 [− 7.0 to − 29.5] % at follow-up, p < 0.001).Our analysis included 102 patients undergoing successful RCA CTO recanalization at the University Medical Center of Mainz. All patients underwent 2DE and 2DSTE to assess RV function before PCI procedure and 6 months after successful revascularization. We found an altered RV function in our collective at baseline assessed by 2DSTE with a significant improvement at 6 month follow-up (baseline RV free wall strain: − 20.7 [− 6.3 to − 32.0] % vs. − 23.4 [− 8.3 to − 39.3] % at follow-up, RV function was altered in patients with RCA CTO and showed significant improvement after successful recanalization. We also noticed an improvement in patient-reported clinical symptoms. Our study suggests that CTO procedure is a beneficial treatment option in symptomatic patients with RCA CTO. The complex anatomy and the volume and pressure dependency represent a challenge for accurate assessment of the right ventricle (RV) with the conventional cardiovascular imaging techniques. As a result, assessment of the RV was neglected for a long time and studies focused on the left ventricle . ImpaireCoronary artery disease is one of the leading causes of death worldwide . RegisteSeveral studies have investigated previously the effect of successful CTO percutaneous coronary intervention (PCI) on left-ventricular function, but data on the RV function are lacking , 19. WitBetween August 2018 and May 2022, 124 patients with RCA CTO underwent successful recanalization at our institution. All patients signed an informed consent for this prospectively conducted study. 2DE and 2DESTE were performed at baseline (before RCA CTO PCI) and at 6 month follow-up after a surveillance coronary angiography confirmed a good result without the need of revascularization within the treated vessel.Patients with valve disease , prior valve surgery or interventional repair, prior cardiac surgery, atrial fibrillation, paced rhythm, left or right bundle branch block, severe pulmonary, kidney  or liver disease, pulmonary hypertension, cardiac surgery, or intervention in the period between study inclusion and follow-up were excluded. Inclusion criteria for our study were proof of viability, successful recanalization of RCA CTO with good angiographic result in the 6 months surveillance coronary angiography [absence of target vessel failure ], sinus rhythm, and sufficient 2-dimensional imaging quality. Only patients whose long-term medication had not changed by the time of the follow-up were included. 102 patients were included in the final analysis . 2DE included two-dimensional views, including apical 4-chamber, apical 2-chamber, and parasternal long-axis views and Doppler imaging analysis. Two cardiac cycles were recorded and analyzed in each view.The RV strain analysis [RV free wall systolic strain (%) and RV global  systolic strain (%)] was performed offline using Q-LAB 13 . Based on the recommendations of the consensus EACVI/ASE/Industry Task Force to standardize deformation imaging, the RV focused 4-chamber view was used, to visualize the entire RV and avoid shortening. RV's region of interest (ROI) was traced along the endocardial border as follows: tricuspid valve annulus, RV free wall, RV apex, septum, and ending at the opposite tricuspid annulus. The ROI was generated automatically, was checked, and, if necessary, the contours were adjusted manually  classification and dyspnea based on NYHA (New York Heart Association).p value of < 0.05 was statistically significant. The statistical analysis was performed using SPSS .Normal distribution of the variables was tested by QQ-plot analysis, the Kolmogorov–Smirnov test, and Shapiro–Wilk test. Categorical data are presented as frequency and percentage, and normally distributed data as mean ± standard deviation and not normally distributed variables are presented as median and interquartile range. To investigate possible differences between baseline and follow-up values, we used the Wilcoxon signed-rank test. Correlations were tested with Spearman's Rho. To investigate possible effects of the right-ventricular side branch (RVSB) on the RV function, we formed four groups  and investigated possible differences between the groups with the Kruskal–Wallis test. A two-sided Of the 102 patients in our final analysis, 72.5% were male with a median age of 66 years (44–80). The mean follow-up period was 187 ± 12.65 days. Median J-CTO Score was 2 (1–3) and most of the patients (54.9%) had Rentrop grade 2 of coronary collateral circulation. Baseline demographical and CTO characteristics are listed in Table p = 0.150). 65 of the enrolled patients reported an improvement in CCS class (63.7% and p < 0.001) and 51 reported an improvement in NYHA class (51.0% and p < 0.001). Complete freedom of angina was achieved in 72.5% of the patients in our collective and 58.8% of the patients reported to having no limitation of physical activity in daily life (NYHA stage 1) at follow-up.Clinical parameters at baseline are shown in Table p 0.203), RV mid-level diameter was 30 mm (22–36) , and RV longitudinal diameter was 70 mm (56–86) . The analysis of the functional parameters at baseline was also within the normal ranges: TAPSE was 20 mm , TDI S’ was 12.3 cm/s  and FAC was 35.01%  in our collective. In our collective, 19 of 102 patients had an impaired TAPSE, and we were able to determine an improvement in all 19 patients in the 6-month follow-up (p < 0.001). 73 out of 102 patients showed an RV-FAC lower than 35%, we observed an improvement in 59 patients after a successful RCA CTO recanalization at the follow-up echocardiography (p < 0.001). 14 out of 102 patients had an impaired TDI and an improvement could be observed in all patients (p < 0.001).The measured RV diameters were within the normal ranges compared to the reference values recommended by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Median RV basal diameter was 36 mm (30–46) at baseline  (p < 0.001).We found significant increase of the functional parameter at follow-up, as shown in Table RV free wall strain was − 20.7 [− 6.3 to − 32.0]% at baseline and RV global strain was − 15.9 [− 6.0 to − 25.7]%, reference values being − 28.5 ± 4.8% for RV free wall strain, and − 24.5 ± 3.8% for RV global strain in healthy subjects . The rigp 0.307; RV global strain and CC grade: correlation coefficient 0.011 and p 0.912; RV free wall strain and Rentrop classification: correlation coefficient − 0.103 and p 0.301; RV global strain and Rentrop classification: correlation coefficient 0.012 and p 0.906).Correlation of coronary collateral circulation (Rentrop und Werner classification) with right-ventricular function after successful CTO PCI was calculated using Spearman’s Rho. We found no correlation between Werner’s classification (CC grade) and right-ventricular function .We investigated whether the location of the CTO [proximal vs. distal to the dominant right-ventricular side branch (RVSB)] influenced right-ventricular function and found no difference between the groups  as determined by intraclass correlation coefficients.To the best of our knowledge, this is the first study analyzing RV function in patients with CTO of the RCA. We assessed RV function with longitudinal strain at baseline and 6 months after successful CTO PCI. Compared to other studies, we only included patients with a good angiographic result in the 6 month surveillance coronary angiography to ensure that the effect on RV function is mainly based on CTO PCI. The main findings of the study were: (1) right-ventricular function is altered in patients with RCA CTO, (2) right-ventricular function improved significantly after successful CTO PCI, and (3) the effect on right-ventricular function is independent of coronary collateralization circulation and the anatomy of the dominant right-ventricular side branch.RV function is an essential parameter for the prognosis and treatment of patients with various diseases, especially after cardiac surgery or interventional therapies –4, 14. OThe benefits of CTO PCI are still controversial. There is evidence that patients benefit from CTO PCI with improved clinical symptoms and quality of life –29. In cOur single-center experience demonstrates a significant improvement of the right-ventricular function assessed by two-dimensional echocardiography and longitudinal strain imaging in patients with RCA CTO after successful recanalization. We also found an improvement in patient-reported exercise tolerance in daily life (NYHA classification) and angina symptoms (CCS classification).This study has a single-center prospective design with a limited sample size and lacks of a control group. Our results, and their potential clinical impact, should be tested in a larger cohort. The longitudinal strain analysis is recommended for an accurate assessment of the right-ventricular function, but the results are dependent on the ankle and pre- and afterload conditions. We tried to reduce the influence of these factors by patients’ selection  and use of clinical parameters  to assess hemodynamic conditions. 2 DE was performed in patients with normotension, sinus rhythm, and no lung disease. However, the RV function is influenced by several factors, which should be taken into account when interpreting our data. Due to the size of our collective and the follow-up period of 6 months, we are not able to evaluate prognostic implications of RCA CTO PCI.


Both the AUC of the isovolumetric contraction and the EF showed a statistically significant correlation with the total work of the ventricle . However, the SV only showed a statistically significant correlation with the EF. A statistically significant one-sample t-test could be found for the EF  and for the AUC of the isovolumetric contraction , but not for the total work of the ventricle. Conclusion: The AUC space of the isovolumetric contraction is a useful marker of ventricular performance in patients with afterload mismatch, showing a statistically significant correlation with the EF and the total ventricular work. This method may have potential for use in clinical practice, especially in challenging cardiological cases. However, further studies are needed to evaluate its usefulness in healthy individuals and in other clinical scenarios.Introduction: The evaluation of myocardial contractility is essential in cardiology practice. The gold standard for this evaluation is the end-systolic elastance, but it the method involved is complex. Echocardiographic measurement of the ejection fraction (EF) is the most commonly used parameter in clinical practice, but it has significant limitations, especially in patients with afterload mismatch. In this study, the area under the curve (AUC) of the isovolumetric contraction was measured to evaluate the myocardial contractility in patients with pulmonary arterial hypertension and severe aortic stenosis. Methods: 110 patients with severe aortic stenosis and pulmonary arterial hypertension were included in this study. The AUC of the isovolumetric contraction was measured using pressure curves of the right ventricle–pulmonary artery and left ventricle–aorta ascendens. This AUC was then correlated with the echocardiographically measured EF, stroke volume (SV), and total ventricular work. Results: The AUC of the isovolumetric contraction showed a statistically significant correlation with the EF of the corresponding ventricle ( The current gold standard method for the non-invasive evaluation of ventricular function is the ejection fraction . The facIn our study, we collected patients admitted to the cardiology department of the General Hospital of Chania, Crete, Greece. All of the included patients were over 18 years of age and were undergoing right and left cardiac catheterization for diagnostic purposes. Only patients with confirmed severe aortic stenosis or pulmonary arterial hypertension were investigated further, while patients with other diagnoses, mild or moderate aortic stenosis, or pulmonary venous hypertension were excluded. The ejection fraction was measured echocardiographically using the Simpson’s biplane method, which involves using the end-diastolic and end-systolic apical 4- and 2-chamber views to estimate the left ventricle volume and calculate the ejection fraction. All echocardiograms were performed by the same operator during the same hospital stay in which cardiac catheterization was performed.The stroke volume was calculated using the Fick method, which is based on the principle that oxygen consumption is equal to the product of the organ’s blood flow (CO) and the difference in the concentration of the substance in the arterial and venous circulation  . In the The product of cardiac output and the maximum pressure difference (which is the difference between the maximum ventricular pressure and the end-diastolic ventricular pressure) is commonly defined as the total work. In this study, we measured three beats in patients with sinus rhythm and five beats in patients with atrial fibrillation, and the average value was used. The measurements were taken during normal breathing, and deep inspirations and expirations were excluded from the analysis.p < 0.05. After the bivariate analysis, a multivariate analysis was carried out to test the independent influence of each parameter. Here, an error probability below 5% (p < 0.05) was also considered significant. Finally, a one-sample t-test was performed for each of these parameters.The evaluation was conducted using the SPSS  23.0G software for Windows. Descriptive statistics were used to determine the usual values, including arithmetic mean, median, standard deviation, standard error, and minimum and maximum values. The correlation coefficient r (Pearson correlation coefficient) and regression coefficient beta were used to describe the correlation between continuous variables. Multiple linear regression analyses were used to represent correlations with several other parameters and to test whether these correlations were significant. The study considered statistical significance to be R² > 0.5 in combination with We developed our research protocol and obtained ethical approval from the ethical committee of the General Hospital of Chania to undertake this study with patients who met the research criteria. We evaluated a total of 110 patients who met the research criteria, out of whom 50 had severe aortic stenosis and 60 had pulmonary arterial hypertension. The exclusion criteria included patients with a bicuspid aortic valve and those with cardiomyopathies, multiple valvulopathies, or other anatomomorphological manifestations.For the patients with severe aortic stenosis, native valve and concomitant mitral regurgitation were considered, and right and left cardiac catheterization were performed to evaluate the stenosis before a transfemoral aortic valve implantation (TAVI). For the patients with pulmonary arterial hypertension, tricuspid valve regurgitations of various gradations were observed, and right heart catheterization was performed for the diagnosis of pulmonary arterial hypertension only, and not as a follow-up. The patients were all untreated at the time of the right heart catheterization, and a medical treatment with a specific pulmonary arterial hypertension medication was initiated for all of the 60 subjects within 30 days post-diagnosis.The patients were required to undergo angiography in the laboratory for catheterization to determine their endovascular pressures and receive a complete anatomic and functional assessment via echocardiography.The entire patient cohort had a mean ejection fraction of 41% . The corresponding stroke volumes were 63 mL , 56 mL (aortic stenosis subgroup), and 68 mL . The end-diastolic pressure for the entire patient cohort was 14 mmHg . The average maximal pressure generated by the left ventricle during systole was 121 mmHg for all patients, 199 mmHg for the aortic stenosis subgroup, and 68 mmHg for the pulmonary arterial hypertension subgroup. The time of isovolumetric contraction was 0.11 s for the entire cohort, 0.09 s for the aortic stenosis subgroup, and 0.12 s for the pulmonary arterial hypertension subgroup.p-value < 0.001).The AUC of the isovolumetric contraction was found to have a statistically significant correlation with the ejection fraction of the corresponding ventricle . This significance remained even after performing a multivariate analysis for both the AUC and the ejection fraction.Both the AUC of the isovolumetric contraction and the ejection fraction were found to be statistically significant with respect to the total work of the ventricle , as did the AUC of the isovolumetric contraction , but the total work of the ventricle did not.One-sample t-tests were performed for the ejection fraction, the AUC of the isovolumetric contraction, and total work of the ventricle. The ejection fraction showed statistical significance  and multivalvular disease, or in determining whether a TAVI will effectively reduce concomitant mitral regurgitation. This method could also provide further information during high-risk PCI to identify patients in need of hemodynamic support (such as an Impella) based not only on statistically proven scores but also on individualized measurements.A clinical prospective study involving healthy individuals or patients at risk of hemodynamic collapse may be unnecessary and ethically questionable. A more realistic approach for a prospective clinical study could involve patients undergoing a coronary angiogram prior to cardiac surgery for aortic or mitral valve disease, regardless of the treatment method .


Peripartum cardiomyopathy (PPCM) affects women at the end of pregnancy or after delivery. Symptoms overlapping with pregnancy decrease the diagnostic yield of PPCM and can increase the rate of maternal mortality. As clinicians manage high-risk patients, it is crucial to understand the variable maternal physiology both during and after childbirth. Effective management of high-risk patients necessitates a comprehensive understanding of the variable maternal physiology during and after childbirth. The importance of prompt intervention with Impella CP (Cardiac Power) to treat acute cardiogenic shock stemming from PPCM after cesarean should be considered. Clinical outcomes can be improved by emphasizing the need for timely intervention and incorporating a comprehensive understanding of maternal physiology. The authors present a case of Impella CP use in PPCM shock as a means for emergent support after cesarean. Peripartum cardiomyopathy (PPCM) is a form of heart failure that primarily affects young women during the later stages of pregnancy or in the months following childbirth. Most PPCM cases are identified after delivery, typically within the first month. It is more commonly observed in African American women and those with advanced maternal age, hypertensive disorders during pregnancy, or multiple pregnancies. The symptoms of heart failure in PPCM often resemble those experienced during a normal pregnancy, contributing to frequent delays in diagnosis.PPCM is a pregnancy-related new-onset heart failure affecting women toward the end of pregnancy or, most commonly, in the week after delivery . AccordiWe present a case of Impella CP (Cardiac Power) use in PPCM shock as a means for emergent support after cesarean section . MinimalA 24-year-old female G1P0 at 36 ½ weeks gestation known to have hypertension, gestational diabetes, and preeclampsia presented with a one-week history of shortness of breath, chest pain, orthopnea, increased lower extremity edema, palpitations, and tachycardia. Upon arrival, an electrocardiogram was done and showed sinus tachycardia with a left bundle branch block  dilatation with an LV end-diastolic diameter of 7 cm with EF estimated to be 20% to 25%. The right ventricle (RV) was mildly enlarged and moderately hypokinetic with an RV pressure of 66 mmHg. Subsequently, she developed significant hypoxemia, and a computed tomography angiography was done to rule out pulmonary embolism or aortic dissection, revealing alveolar changes and an enlarged cardiac silhouette. These findings prompted a cesarean section, delivering a healthy baby.After her cesarean section, she had episodic supraventricular tachycardias that were unresponsive to adenosine and required initiation of intravenous amiodarone. Due to further decompensation, requiring a high-flow nasal cannula, she underwent evaluation for acute mechanical circulatory support while on norepinephrine 0.02 mcg/kg/min and milrinone 0.25 mcg/kg/min. Ultimately requiring intubation, she was taken to the cardiac catheterization lab for femoral Impella CP placement  and attempt to wean inotropic support with the hope of myocardial recovery.Pre-impella pulmonary artery (PA) catheterization revealed right atrial pressure (RA) of 18 mmHg, PA pressure of 45/21 (29) mmHg, pulmonary capillary wedge pressure (PCWP) of 37 mmHg, left ventricular end-diastolic pressure (LVEDP) of 32 mmHg, cardiac output of 2.5 L/min, and cardiac index 1.37 L/min/mScreening and management of PPCMGiven the broad differential for shortness of breath in gravid females, our case provides insight into early screening and diagnosis for PPCM with a surface echocardiogram. Upon suspicion of PPCM, echocardiography should be performed, as the left ventricular ejection fraction (LVEF) is typically <45% when establishing the diagnosis . UtiliziAs providers manage high-risk patients, it is crucial to understand the variable maternal physiology both during and after childbirth. In this case, we describe treatment options that are safe and effective yet often overlooked. Supporting post-partum mothers with mechanical support and allowing time for organ recovery and optimization of deranged hemodynamics, vascular tone, and hormone cascades during the critical period after delivery is key in their management. The importance of prompt intervention with Impella CP to treat acute cardiogenic shock stemming from PPCM after cesarean should be considered. This case explores the utility of early intervention after cesarean and support with Impella CP placement as a bridge to recovery from PPCM. Salvage therapy with the Impella CP as a bridge to recovery, transplant, or durable ventricular assist device can be a viable option in the subset of patients with acute shock. By providing hemodynamic stabilization and LV unloading, Impella CP plays a crucial role in managing severe myocardial insult and cardiogenic shock associated with PPCM. Physicians must be aware of the challenges in diagnosing PPCM promptly due to overlapping symptoms with normal pregnancy and the postpartum period. Our article highlights the importance of Impella CP in the management of acute cardiogenic shock arising from PPCM after cesarean.


LV mass was higher in LGE + males (86 ± 18 g/m2) compared to LGE- males . Furthermore, LGE + males had lower weight  and shorter best marathon finishing times (3.2 ± 0.3 h) compared to LGE- males  suggesting higher training load in these runners to accomplish the marathon in a short time.Contrast-enhanced CMR revealed focal myocardial fibrosis in 8 of 74 runners (11%). The majority of runners were male . LGE was typically non-ischemic in 7 of 8 runners (88%) and ischemic in one runner. ECV was higher in remote myocardium without LGE in male runners (25.5 ± 2.3%) compared to male controls (24.0 ± 3.0%, The high frequency of non-ischemic myocardial fibrosis in LGE + male runners can be related to increased LV mass in these runners. Furthermore, a higher training load could explain the higher LV mass and could be one additional cofactor in the genesis of myocardial fibrosis in marathon runners.• A high frequency of myocardial fibrosis was found in marathon runners.• Myocardial fibrosis occurred typically in male runners and was typically non-ischemic.• Higher training load could be one cofactor in the genesis of myocardial fibrosis in marathon runners. Regular physical activity is generally considered beneficial for the cardiovascular system and is associated with improvement in physiological parameters . Recent It is recognized that late gadolinium enhancement (LGE) quantified by cardiac magnetic resonance (CMR) imaging occurs in both acute and chronic (scar) infarctions and in an array of other myocardial processes that cause myocardial necrosis, infiltration, or fibrosis . These mPrevious CMR studies showed a high prevalence of focal myocardial fibrosis in up to 50% of asymptomatic athletes with still controversial clinical relevance –18. LifeThe present study analyzed the prevalence and pattern of focal and potential diffuse myocardial fibrosis detected by LGE and ECV in male and female marathon runners using contrast-enhanced CMR.This prospective single-center observational study was approved by the local institutional ethics committee. All subjects gave written informed consent before study participation. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.Male and female marathon runners were contacted through advertisements at local running clubs. They were included with a self-reported regular training of at least 10 h per week and a history of at least one completed marathon race. A standard questionnaire was used to assess the weekly training load and lifetime competition history, including completed marathons and finishing times. The best marathon finishing time referred to a marathon distance of 42.195 km defined by World Athletics. Each runner completed at least one marathon with that distance and reported the corresponding finishing time. Controls with similar age and sex were eligible if they exercised less than 3 h per week. Subjects with contraindications for CMR were excluded. All subjects reported no cardiovascular disease and all subjects denied any cardiac or illicit medication intake. All subjects underwent the CMR study before the exercise test, which was performed on the same day. Subjects were instructed to arrive rested with no exercise and no alcohol intake in the preceding 72 h. Any food and caffeine intake was restricted in the preceding 3 h before the CMR and the exercise test was performed 3 h after the CMR.2max) and ventilatory threshold. A 12-lead electrocardiogram and heart rate were monitored continuously, and blood pressure was automatically measured every 2 min. The ramp incremental step-exercise test was preceded by a 2-min rest period and unloaded cycling (20 W for 3 min), until a steady state was attained. Depending on the subject´s training history, the ramp was continuously increased by 20 to 40 W/min to bring the participants to the limit of tolerance within 10 to 12 min of exercise.Cardiopulmonary exercise testing was performed on the same day after CMR using an eddy current braked cycle ergometer  to determine maximal oxygen uptake .Runners and controls underwent CMR imaging with a 1.5-T Achieva Scanner , using a 5-element cardiac coil and ECG gating. Conventional balanced steady-state free-precession (SSFP) cine imaging in the short axis covering the left ventricle (LV) and right ventricle (RV) was obtained for volumetry and LV mass. A Modified Look-Locker Inversion Recovery (MOLLI) sequence with a 5 s(3 s)3 s scheme on 3 short-axis slices  before and 15 min after administration of contrast medium was used to perform T1 mapping and ECV quantification. Additionally, after 10 min of a bolus injection of 0.2 mmol/kg gadoterate meglumine , end-diastolic LGE images were acquired with standard phase-sensitive inversion recovery (PSIR) sequences in short axis orientation and in 2-, 3-, and 4-chamber views matching cine images. Details about the scanning protocol were previously reported .Two experienced observers  independently and blindly analyzed CMR images using cvi42 software (Circle Cardiovascular Imaging Inc.). CMR parameters were normalized to the subject’s calculated body surface area (BSA) and are given as the mean of the two investigators’ measurements. LV and RV volumes and LV mass were measured on short-axis cine images as previously described . Focal mp < 0.05.Statistical analysis was performed using GraphPad Prism for MacOS, Version 9.1.1 (GraphPad Software Inc.). All MR imaging data are presented as means of the measurements from two blinded readers. The normality of the data was assessed by Shapiro–Wilk test. Continuous data are presented as mean ± SD, and categorical data are presented as absolute numbers and percentages. Continuous variables were compared between groups using unpaired 2-sided student’s t-tests. For categorical data, the chi-square test or Fisher’s exact test was used as appropriate. Statistical significance was defined as 2max as compared to controls . No LGE was detected in the controls. LGE was midmyocardial or subepicardial localized in 7 of 8 runners (88%). One runner had subendocardial LGE typical for myocardial infarction (runner 12)  in male LGE + runners and 2.2%LV and 1.2 g/m2 in the one female LGE + runner  and the majority of these 8 LGE + runners were male . The prevalence of LGE was 7 in 55 male runners (13%) and one in 19 female runners (5%), however, the LGE difference between both genders was not significant  had lower weight , lower body surface area , and lower body mass index  compared to LGE- males . All other standard CMR parameters including LVEF, LV, and RV volumes were similar between groups. Furthermore, native T1 and ECV values were not different in both groups indicating no incremental potential diffuse myocardial fibrosis in LGE + males. The competition history revealed that the best marathon finishing time was with 3.2 ± 0.3 h shorter in LGE + males compared to LGE- males with 3.6 ± 0.4 h (p < 0.05). All other training and competition history parameters were similar in both groups.LGE + males  had LGE, which was typically non-ischemic with midmyocardial or subepicardial localization . ECV was slightly higher in male runners compared to controls in remote myocardium without LGE indicating the potential presence of diffuse myocardial fibrosis. LGE + males had higher LV mass compared to LGE- males, indicating a more pronounced adaption of the heart to exercise. LGE + males had lower weight at similar height compared to LGE- males, revealing a more asthenic build in these runners. LGE + males had a shorter best marathon finishing time suggesting a better fitness level for these runners, although exercise testing revealed no difference in performance measured by VOp = 0.14). One potential explanation is viral myocarditis, which involves males twice as often as females [The prevalence of myocardial fibrosis by LGE was 11% in all marathon runners and 13% in male runners in the current study. The current LGE prevalence is somewhat lower compared to a previous study with 17% in male LGE + triathletes . Further females . Despite females . This asBesides myocarditis, other factors can be responsible for the preferential occurrence of myocardial fibrosis in males. LGE at the RV insertion points is a frequent finding in patients with pulmonary hypertension . Current2 compared to previously studied male LGE + triathletes with 3.5 ± 2.8%LV and 2.9 ± 2.3 g/m2 [The mean size of LGE was smaller in our male runners with 2.5 ± 1.8%LV and 1.9 ± 1.8 g/m2.3 g/m2 . Our dat2.3 g/m2 .ECV was slightly increased in male runners with 25.5 ± 2.3% compared to controls with 24.0 ± 3.0% in remote myocardium without LGE indicating the potential presence of diffuse myocardial fibrosis. One explanation could be hypertensive heart disease, where there is an expansion of both the myocyte volume resulting from myocyte hypertrophy (intracellular) as well as the interstitial space resulting from fibrosis (extracellular) . HoweverOne runner had subendocardial LGE typical for myocardial infarction and he received secondary prevention medication. This runner was not aware of having coronary heart disease and he was asymptomatic during exercise and competition. Therefore, we did not recommend invasive or computed tomography coronary angiography for further testing.LGE + males had lower weight at similar height compared to LGE- males, revealing a more asthenic build in these runners. This finding could be explained by more intensive training in LGE + males, although our standard questionnaire revealed no differences in the weekly training load and the number of active years. However, we found that the best marathon finishing time was shorter in LGE + males compared to LGE- males suggesting a higher fitness level most likely related a more intensive training in these runners. Our standard questionnaire was not designed to document the exact training load before a competition and limited a detailed analysis of the impact of training on the occurrence of LGE. For example, the individual training volume and intensity varies between runners and depends on multiple factors such as motivation, health condition, available time, and so forth. Therefore, a more exact documentation of the individual training absolved by the athlete could be helpful to better understand the training differences in LGE + and LGE- athletes and the impact of training on LGE in athletes in general. The training regimen of athletes is most likely the more important aspect to further study on, since training repeatedly consumes much more time and effort, compared to the “relatively short” marathon distance during one competition.LV mass was higher in LGE + males compared to LGE- males. A similar finding was previously reported in triathletes . CurrentWe used a standard questionnaire to assess the self-reported training load in our runners. Currently, more precise techniques are available to assess physical activity during training such as quantifying the metabolic equivalent (MET), which was developed to enhance the comparability of results across studies using self-reported physical activity . Future The current study revealed typically non-ischemic myocardial fibrosis in 7 of 55 (13%) male marathon runners and in one of 19 female runners (5%). Furthermore, we found slightly higher ECV in remote myocardium without LGE in male runners compared to controls demonstrating the potential presence of diffuse myocardial fibrosis possibly related to hypertensive heart disease. No ECV differences were found in female runners and controls. LGE + males had higher LV mass compared to LGE- males, indicating a more pronounced adaption of the heart to exercise. Furthermore, LGE + males had lower weight and shorter best marathon finishing time suggesting a better fitness level and higher training load to accomplish the marathon in a short time. The higher training load can explain the higher LV mass and could be one additional cofactor in the genesis of myocardial fibrosis in athletes. Since the clinical relevance of the observed myocardial fibrosis is currently not clear we did not give any specific recommendation to reduce the individual sports practice in LGE + runners. Further studies are needed to analyze the impact of training load on the occurrence of myocardial fibrosis in athletes and the long-term relevance of myocardial fibrosis on left ventricular function and on the occurrence of relevant cardiac arrhythmia.


The growing global prevalence of heart failure (HF) necessitates innovative methods for early diagnosis and classification of myocardial dysfunction. In recent decades, non-invasive sensor-based technologies have significantly advanced cardiac care. These technologies ease research, aid in early detection, confirm hemodynamic parameters, and support clinical decision-making for assessing myocardial performance. This discussion explores validated enhancements, challenges, and future trends in heart failure and dysfunction modeling, all grounded in the use of non-invasive sensing technologies. This synthesis of methodologies addresses real-world complexities and predicts transformative shifts in cardiac assessment. A comprehensive search was performed across five databases, including PubMed, Web of Science, Scopus, IEEE Xplore, and Google Scholar, to find articles published between 2009 and March 2023. The aim was to identify research projects displaying excellence in quality assessment of their proposed methodologies, achieved through a comparative criteria-based rating approach. The intention was to pinpoint distinctive features that differentiate these projects from others with comparable objectives. The techniques identified for the diagnosis, classification, and characterization of heart failure, systolic and diastolic dysfunction encompass two primary categories. The first involves indirect interaction with the patient, such as ballistocardiogram (BCG), impedance cardiography (ICG), photoplethysmography (PPG), and electrocardiogram (ECG). These methods translate or convey the effects of myocardial activity. The second category comprises non-contact sensing setups like cardiac simulators based on imaging tools, where the manifestations of myocardial performance propagate through a medium. Contemporary non-invasive sensor-based methodologies are primarily tailored for home, remote, and continuous monitoring of myocardial performance. These techniques leverage machine learning approaches, proving encouraging outcomes. Evaluation of algorithms is centered on how clinical endpoints are selected, showing promising progress in assessing these approaches’ efficacy. The most recent findings from the Global Burden of Disease (GBD) study show that heart failure (HF) affects more than 64 million people globally on a spectrum of severity . Around Early recognition of heart failure is essential for underlying diseases or causes to be successfully treated and, in certain individuals, to stop further myocardial dysfunction and clinical decline. According to the Canadian cardiovascular society, suspected HF patients should firstly have a detailed clinical history as well as a physical examination to affirm or exclude myocardial dysfunction . Vital sTo improve the potential of heart failure, systolic and diastolic dysfunction diagnosis, classification, and characterization, the currently used non-invasive sensor-based technologies can be broadly classified into two distinct primary categories. The first group focuses on techniques that allow for a subtle investigation of cardiac dynamics through indirect patient contact . The balThe second category includes methodologies operating under a non-contact paradigm, thus avoiding direct physical interaction with the patient. This compilation of techniques encompasses an array of advanced approaches, each contributing to a refined understanding of cardiac dynamics . AlongsiThese simulated manifestations enable the intricate exploration of cardiac performance without needing direct interaction with a living subject by simulating real-world conditions with a controlled platform. Moreover, increasing the capacity to generate synthesized data mirroring cardiac activities under assorted conditions. This synthetic data can be harnessed to cultivate and train machine learning algorithms earmarked for the analysis of sensor data. Such endeavors notably contribute to the advancement of non-invasive methodologies pertaining to cardiac monitoring through the lens of contemporary artificial intelligence tools.Diverse levels of models replicating the systolic and diastolic heart failure have been introduced so far. Many researchers built up heart models to analyze the hemodynamic variations in the systolic and diastolic dysfunction including ejection fraction, stroke volume, blood volume, peripheral resistance, and cardiac output. The tissue level models study muscular contractility, left ventricle twisting/torsion, and myocardial strain . WhereasThe clinical efficacy of myocardial and other cardiovascular biomarkers in the context of heart failure (HF) has been linked. However, due to their limited cardiac and HF specificity, many of these biomarkers do not meet the established criteria for prescription, as stipulated by relevant standards . MoreoveVarious non-invasive sensing technologies used to characterize myocardial performance; we conducted a review of the field to outline the non-invasive sensor technologies and minimally invasive techniques employed for heart failure diagnosis, compare current practices, explain model limitations, and pinpoint knowledge needs for future study. The research inquiries pertain to the exploration of whether non-invasive sensor-based technologies exhibit adequacy in detecting heart failure, and systolic/diastolic dysfunction. Furthermore, the study seeks to elucidate the potential role of heart phantoms in enhancing the laboratory’s ability to detect heart failure.The pathological state of heart failure results in less effective blood pumping. As the metabolizing tissues require it to, or only possible with elevated filling pressure. Heart failure diagnosis usually consists of the following: echocardiogram (EKG) or transthoracic echocardiogram (TTE), radionuclide ventriculography or radionuclide angiography (MUGA scan), cardiac computed tomography (CCT) scan, blood tests, such as natriuretic peptide tests, electrolyte panel and cardiac catheterization .In systolic heart failure ejection fraction is decreased (HFrEF) since the heart cannot contract normally. Conversely, with absence of a decreased EF, diastolic heart failure pathological situation is detected when the heart cannot fill adequately. The anatomical characteristics of the left ventricle (LV) are identical for systolic and diastolic dysfunction, increasing mass of left ventricle and LV end-diastolic pressure are two examples. Although symptoms, prognosis, and signs are very similar; the most obvious distinction between both types of heart failure is left ventricle function and geometry; systolic heart failure is defined by dilatation of left ventricle, eccentric hypertrophy of LV, and unusual systolic and diastolic functioning, However, semi-circular LV hypertrophy, a normal EF, and variable diastolic performance are the hallmarks of diastolic dysfunction .The paradigm of using ejection fraction (EF) to categorize HF evolved when studies in the early 2000s revealed a bimodal pattern of EF throughout HF patients . The EurNon-invasive sensing technology used in modeling cardiac abnormalities can consist of distinct types of heterogeneous sensors. The various sensor configurations depend on the sort of sensing technology used . These mNoninvasive and unobtrusive vital sign sensing is made possible by technological developments in hardware and software. BCG is a technique of acquiring the reaction of the pushed-out blood when the heart beats, these vibration signals are indirectly detected using load sensors fastened to a chair or bed. The primary challenge is how to improve the use of BCG technology, with a focus on varies devices used for measurement, and signal processing approaches. Diastolic and systolic blood pressure monitoring based on BCG was adapted, showing good opportunities for cuff-less pressure measurements . BCG sigEarly HF changes were shown in a female older adult using BCG sensors embedded under a bed mattress , the anaFeng et al. used a non-contact piezoelectric sensing device and the echocardiography to detect HF patients with LVEF ≤49 . ThroughIt is recognized as a diagnostic method for assessing the electrical characteristics in the thorax biological tissues. In this technique, two outer electrodes are used to provide a small, alternating, constant current that has an amplitude between 1 and 5 mA and a frequency between 20 and 100 kHz. Two inner electrodes are then used to measure the electrical voltage difference . ICG limIn another study , researcHowever, researchers in  targetedThoracic fluid content (TFC) is obtained using the ICG device from heart failure patients with dyspnea and are suspected of pulmonary oedema (PO) . They caPPG is a wearable optical tool that is used non-invasively in blood circulation to measure volumetric fluctuations. This is achieved by a light source and a photodetector at the surface of the skin. Important health-related information is contained in PPG wave . To evaluate several cardiovascular-related disorders , can thus, be achieved by the examination of this waveform for doctors and researchers. Also, analyzing the PPG second derivative signal can be helpful in early diagnosis and detection of different cardiovascular diseases that could potentially manifest in life . While rIn another work, by using only heart rate variability (HRV) collected from photoplethysmography, machine learning model was enhanced to detect HFrEF and HFpEF . VolunteBlood pressure estimation (BPE) is another significant evaluation from the recorded PPG signal . ResearcIn another work, using data augmentation 10s PPG signals were converted into a 128 × 1,024×3 time-frequency chromatograph , then thOne of the most popular non-invasive diagnostic techniques for monitoring the heart’s physiological processes throughout time is the electrocardiogram (ECG). Many cardiovascular disorders, including atrial fibrillation, myocardial infarction, premature contractions of the ventricles or atria, and congestive heart failure, can be diagnosed with the help of ECG data. Wearable technology in the healthcare industry, including the Apple Watch and portable ECG monitors like the Holter monitor, have both developed quickly in recent years. As a result, human cardiologists are struggling to keep up with the growing volume of ECG data that needs to be analyzed. Consequently, automatic and accurate ECG data analysis has become a popular study area, especially using AI tools. The diagnostic golden rules have been used for automatic ECG analysis. This process consists of two steps, that involve human specialists to create meaningful features from raw ECG data, known as “expert features,” and then to come at inferences, using prediction model or other machine learning approaches. These features could be categorized into coefficients of variation and density histograms, statistical features , frequency-domain features, time-domain features and sample entropy.t-test, minimum redundancy maximum relevance (mRMR), random forest (RF), and Wilcoxon methods. And classification accuracy of 99.86% was reported in this study. Whereas in  based heart phantom was created that resembles the form of the heart including the characteristics of MRI and ultrasound imaging. Further phantom with pathologic characteristics that mimicked an aneurysm and scarred areas was used  shaped phantoms composed of various materials that could be imaged using cardiac magnetic resonance (CMR), cardiac computed tomography (CT) and RT3DE , a new 3D-CT to 2D-US registration technique was created . This phFurthermore, researchers in  aimed to1. Extracted features and home monitoring: Linear and nonlinear features derived from BCG signals showed significant distinctions between normal and heart failure patients. Home monitoring technologies have embraced diverse configurations of embedded BCG sensors, indicating promising prospects for future tele monitoring of heart failure patients.2. ICG potential: Impedance signals appear as a potential source of heart rate information through beat-by-beat analysis. Continuous monitoring of systemic vascular resistance, stroke volume, cardiac output, and systolic time intervals stands as exemplary clinical applications of this technique.3. Significance of PPG wave: The PPG waveform encapsulates a wealth of health-related information, encompassing vascular dynamics, oxygenation levels, heart rate, and rhythm. comprehensive analysis of this waveform holds potential in diagnosing various cardiovascular disorders, including arterial stiffness and atherosclerosis4. ECG as a diagnostic instrument: ECG reigns as a preeminent non-invasive diagnostic tool for real-time monitoring of cardiac physiological processes. Its application extends to the diagnosis of diverse cardiovascular ailments, encompassing atrial fibrillation, myocardial infarction, ventricular and premature atrial contractions, and congestive heart failure.5. Integration of Deep Learning: Modern technological advancements harness deep learning models to autonomously and implicitly extract features from ECG data. These models further simulate heart failure based on ECG data, augmenting diagnostic capabilities.6. Role of heart simulators: Heart simulators, adept at emulating the mechanical dynamics of the heart, yield dependable and replicable outcomes. They facilitate meticulous process and system comparisons, thereby underpinning reliable advancements in cardiac research and diagnostics.1. Variability in BCG design: The design of the fixed template for BCG exhibits significant variability contingent on the dynamic measurement conditions. Consequently, it does not conform to a universal standard. The alterations in patient movement, postural adjustments, electrode placement, blood composition, skin moisture levels, ambient radiofrequency interferences, and even variations in body composition collectively contribute to the constraints met in ICG.2. Challenges in Real-Time PPG: Acquiring a real-time PPG signal while mitigating considerable artifacts presents a notable challenge. The comprehensive assessment of the influence of diverse noise sources on the real-time PPG signal and the subsequent development of methodologies for their effective elimination from the acquired signal are components integral to forthcoming research endeavors.3. ECG measurements can be influenced by factors such as electrode placement variability, patient movement artifacts, and interference from external electromagnetic sources. Additionally, while modern technology leverages deep learning models to enhance ECG data analysis, the interpretability of these models remains a challenge.4. Heart simulators for imaging tools: The primary design orientation of heart simulators is geared towards accommodating imaging assessment tools. These simulators are characterized by their applicability to high-cost prototyping and maintenance. As indicated in the reviewed literature, the predominant focus of heart simulators lies in serving imaging methodologies, underscoring their specialized utility in this context.While exploring various methodologies and technologies for cardiovascular assessment, it is important to acknowledge certain limitations that appear during their application. This section highlights several constraints and challenges encountered in the implementation of these techniques.Based on the analysis and findings presented in the study, to support the creation and adoption of non-invasive sensor-based technologies, foster collaboration between researchers, engineers, physicians, and industry stakeholders. Working together can assist in solving technological issues, encourage data exchange, and hastening the conversion of research into clinical practice. However, to evaluate the precision, dependability, and generalizability of sensor-based models for heart failure, systolic and diastolic dysfunction, comprehensive validation studies involving various patient populations should be carried out. To guarantee the clinical relevance and efficacy of these technologies across various patient profiles and healthcare contexts, robust validation is essential.Also, concentrate on the creation of wearable sensors and remote monitoring systems that can track important physiological characteristics over a long time. Long-term monitoring can offer insightful information about the course of the disease, the effectiveness of the treatment, and the early identification of exacerbations, allowing for prompt interventions and individualized care. Devote close attention to how user-friendly and satisfying non-invasive sensor-based solutions are; create mobile applications with user-friendly interfaces and clear instructions so that patients and healthcare professionals can quickly explore and comprehend the gathered data. Patients can be empowered to participate in their own care and make educated decisions with clear visualizations and timely alerts.Also, it is important to assert privacy issues and make sure that effective security procedures are in place to safeguard private patient information obtained via non-invasive sensors. Maintaining patient trust and ensuring ethical use of the gathered data depend on compliance with data protection laws and regulations. Machine learning were used widely for the identification of the heart failure clinical cases, although accuracy is affected by algorithm type and data size, frame rates of the imaging outcomes and physician intervention is critical leading to different models from hospital to the other.Deep learning approaches—which are more potent and effective ways to handle the enormous volumes of data generated—evolved from machine learning approaches, has proven to have potential for use in heart failure modeling. Although it is a black box technique, some studies showed promising results on evaluating the algorithms based on how clinical end point choice is made.Heart dysfunction is the cause of worrisome patient outcomes, a subsequent high-rate mortality, and increased economic loss. The creation of precise and individualized models for heart failure prediction, diagnosis, and management has been made possible by the integration of non-invasive sensing technologies including BCG, ICG, PPG, ECG, and imaging-based heart simulators. These sensor-based models can offer insightful information about the development and severity of heart failure by using analytics and machine learning approaches. To enhance patient outcomes and quality of life, they have the capacity to identify early warning signals, predict exacerbations, and perfect treatment approaches. Furthermore, the potential for remote monitoring provided by non-invasive sensor-based technology allows healthcare personnel to track patient status from a distance and take proactive action when necessary. This can result in prompt interventions, fewer hospital stays, and better patient management, especially for those with chronic or severe heart failure.The widespread application and adoption of non-invasive sensor-based technology for heart failure modeling still faces difficulties, nevertheless. Data integration, interoperability, privacy issues, and the requirement for validation across a range of patient populations are some of these difficulties. To guarantee that these technologies are useful and prevalent for patients and healthcare professionals, it is also crucial to address their usability and accessibility issues.To sum up, non-invasive sensor-based technologies have enormous potential for developing heart failure, systolic and diastolic dysfunction modeling. These technologies have the potential to transform cardiac dysfunction management and greatly enhance patient care and outcomes with sustained study, technological breakthroughs, and collaboration between researchers, engineers, and physicians.


Heart failure caused by iron deposits in the myocardium is the primary cause of mortality in beta-thalassemia major patients. Cardiac magnetic resonance imaging (CMRI) T2* is the primary screening technique used to detect myocardial iron overload, but inherently bears some limitations. In this study, we aimed to differentiate beta-thalassemia major patients with myocardial iron overload from those without myocardial iron overload (detected by T2*CMRI) based on radiomic features extracted from echocardiography images and machine learning (ML) in patients with normal left ventricular ejection fraction (LVEF > 55%) in echocardiography. Out of 91 cases, 44 patients with thalassemia major with normal LVEF (> 55%) and T2* ≤ 20 ms and 47 people with LVEF > 55% and T2* > 20 ms as the control group were included in the study. Radiomic features were extracted for each end-systolic (ES) and end-diastolic (ED) image. Then, three feature selection (FS) methods and six different classifiers were used. The models were evaluated using various metrics, including the area under the ROC curve (AUC), accuracy (ACC), sensitivity (SEN), and specificity (SPE). Maximum relevance-minimum redundancy-eXtreme gradient boosting (MRMR-XGB) , ANOVA-MLP , and recursive feature elimination-K-nearest neighbors (RFE-KNN)  were the best models in ED, ES, and ED&ES datasets. Using radiomic features extracted from echocardiographic images and ML, it is feasible to predict cardiac problems caused by iron overload.The online version contains supplementary material available at 10.1007/s10278-023-00891-0. One of the common forms of inherited anemia caused by a malfunction with hemoglobin synthesis is thalassemia . ApproxiPatients with thalassemia major require frequent blood transfusions due to severe anemia, and regular blood transfusions cause iron overload in these patients . Iron ovIdentifying and measuring iron deposits, especially in the heart, in patients with thalassemia major with frequent injections and patients receiving chelation treatments should be considered. There are several methods to evaluate and control iron overload. Serum ferritin level, as the broadest tool with the lowest cost in assessing the body’s iron concentration , may chaCardiac magnetic resonance imaging (CMRI) is a non-invasive method to evaluate cardiac iron deposits. Moreover, T2*CMRI is an outstanding and non-invasive technique in evaluating myocardial iron deposits –20. T2* Echocardiography is a method to identify cardiac dysfunction caused by iron overload in patients with thalassemia major. In studies conducted by Abtahi et al.  and KhalIn a study conducted by Baessler et al. , the abiThe main objective of this study is to utilize echocardiography radiomic features and ML algorithms to identify individuals at risk of developing cardiac issues in the near future due to excessive iron accumulation in their hearts. These individuals have been categorized based on CMRI T2* results.The framework of the study is shown in Fig. Ninety-one patients with an age range of 15 to 50 years (31 ± 7.56 years) were enrolled in this study. Forty-four patients with thalassemia major (age: 30.40 ± 7.05 years) whose heart condition was examined and followed up at a maximum interval of 6 months by echocardiography and CMRI were included in the study. Patients had normal echoes (LVEF > 55%) and T2* ≤ 20 ms in CMRI. In addition, 47 people (age: 33.23 ± 7.75 years) and conditions as thalassemia patients who had an echo and CMRI tests conducted at a maximum interval of 6 months and those with LVEF > 55% and T2* > 20 ms were entered into the study as the control group. Table Two-dimensional M-mode and Doppler echocardiography  and tissue Doppler echocardiography were performed using the echocardiography system by the transthoracic method in supine. Left lateral decubitus positions for all subjects were performed to obtain a 4-chamber view. Within less than 6 months, patients with thalassemia major and those selected as the control group were subjected to CMRI examinations. MRI examinations were performed using a 1.5 Tesla scanner (Avanto-Siemens). To evaluate cardiac T2*, a black-blood multi-gradient echo sequence was obtained in short axis view with 8 echo times (TE) and 10 mm slice thickness. In addition, fast spin echo sequences were routinely performed to examine the morphology of the heart. Myocardial function was evaluated using cine CMRI protocols such as steady-state free precession (SSFP) with a slice thickness of 8 mm and a gap of 2 mm in the short and long axis .After obtaining the echo images in the video, the frames of the end-systolic (ES) and end-diastolic (ED), according to the patient’s electrocardiogram, were extracted from all the frames related to the 4-chamber view. Furthermore, filtration was also done on them due to the low quality and high Speckle noise. The linear statistical filter DsFlsmv, which had the best performance and had the most negligible impact on the radiomic analysis , was appn = 21), shape (n = 1), and texture ((n = 32), GLCM = 7, GLRLM = 11, NGLDM = 3, GLZLM = 11). After extracting the features and classifying the data into two classes (class 1 representing the patients and class 0 representing the control group), the data were divided into two categories: the train  and the test  using stratification.In order to extract radiomic features in LIFEx v7.2.0 software , which iZ-score. In more detail, the training dataset was standardized, and the derived mean and standard deviation (SD) were applied to the test dataset. Analysis of variance (ANOVA), maximum relevance-minimum redundancy (MRMR), and recursive feature elimination (RFE) feature selection methods were used to select the features. Random forest is used as the core of the RFE feature selection approach because it is flexible, resistant to overfitting, computationally efficient, and produces feature importance scores [Before FS and the implementation of ML algorithms, some preprocessing on the train dataset was implemented. The radiomic features with zero variance were removed, and correlation between features was investigated using Spearman’s statistical analysis. One of the two features that had an absolute correlation coefficient > 0.90 with each other was removed. Then, feature standardization was done using e scores .After selecting a certain number of features as input to the models, various types of models such as K-nearest neighbors (KNN), logistic regression (LR), multi-layer perceptron (MLP), random forest (RF), support vector machine (SVM), and eXtreme gradient boosting (XGB) were applied to the data. The architecture of MLP can be found in the supplementary under the heading “The Multi-Layer Perceptron (MLP) architecture”. The data were divided into three categories to feed the ML algorithms: first, only the radiomic features extracted from ED images; second, the radiomic features extracted from ES images; and finally, the combination of the features of these images (ED and ES). Considering 3 separate datasets, 3 FS methods, and 6 different classifiers, a total of 54 models were implemented in this study. GridSearch was used to optimize hyperparameters in the training dataset with 10-fold cross-validation. The best hyperparameters were chosen for the trained model, which was then applied to the test dataset using 1000 bootstraps.P value to estimate the significance of the observed difference [P values under 0.05 were regarded as statistically significant. Furthermore, feature maps of four of the most selected features with the highest scores across the three different FS methods were designed for two cases, including a case from the control group (T2* > 20 ms) and a case from the group of patients prone to develop iron overload (T2* ≤ 20 ms). The Pyradiomics version 3.0.1 [Various metrics including the area under the receiver operating characteristic (ROC) curve (AUC), accuracy, specificity, and sensitivity were used to evaluate the performance of the models. In addition, all model’s AUCs were compared using the DeLong test . The DeLfference . P valueon 3.0.1  was usedon 3.0.1  using “mon 3.0.1 , “ggploton 3.0.1 , “caret”on 3.0.1 , and “pron 3.0.1  librarieThree feature selection methods including ANOVA, MRMR, and RFE were applied on the three datasets , and 10 features were selected in all the datasets for the ANOVA and MRMR methods. Moreover, for RFE, 12, 11, and 8 features were selected in ED, ES, and ED&ES datasets, respectively. Selected features with their scores for ANOVA and MRMR, the linear diagram, and selected features related to the RFE are presented in Figs. The results of all the models used using six classifiers  and three FS  on three separate datasets  are shown in Fig. q values compared to other models, respectively.Figure Despite recent developments, heart failure resulting from iron deposition in patients with thalassemia major is still the most serious and the leading cause of death . FurtherAccording to Fig. Barzin et al.  stated tModel explainability seeks to identify a distinctive set of biomarkers, known as a signature, to potentially predict a clinical outcome, such as a diagnosis, prognosis, or response to treatment. In the realm of radiomics, intriguing research has been carried out recently. However, there is a lack of emphasis on developing explainable models. The essence of explainable models lies in their ability to gain approval and trust from physicians in clinical setting. When a model is developed, it becomes crucial to demonstrate to physicians that it is not just a black-box computerized system. By providing explanations for the model’s outcomes, it can foster confidence and encourage the utilization of these models in practice .The important issue is that many of the developed models are not easily interpretable. Physicians and clinicians cannot easily understand and subsequently trust them because of their black-box nature . In Fig.In the ED dataset, the MRMR-XGB model achieved the best result. In the ES dataset, the top models were MLP using ANOVA and KNN using RFE. In the ED&ES dataset, RFE-KNN had the best result. The results of the models in the ED dataset are superior to those of each set of features. The explanation is that the motion of the heart is the lowest in the mid-to-end-diastolic phase; this probably causes the distortion of the features to occur less and get a better result.According to our findings, using radiomics extracted from echo images, it is possible to classify individuals which are labeled according to CMRI T2*. Meanwhile, the subjects examined in this study had normal results in terms of LVEF, and no dysfunction was evident. In other words, based on image analysis, echo radiomic features are related to the T2* value. While in conventional echocardiography studies, Moussavi et al.  found noOur study emphasizes the high ability of radiomics in the early detection of cardiomyopathy resulting from iron deposition in conditions where LVEF is preserved. Therefore, the presented findings could potentially help physicians make decisions regarding heart failure caused by iron deposition using echo images. In such a way, physicians can successfully reverse the condition of cardiomyopathy and prevent the progression of the disease with early diagnosis. Furthermore, since echocardiography has a lower cost than a method like MRI and is available in most centers, this method is cost-effective in evaluating heart failure in patients with thalassemia. In addition, echocardiography is non-invasive as well as portable.This study had some limitations. First, we have a small sample size as we select patients with echo and CMRI studies in short time intervals with a max 6-month duration; a larger sample in future studies would be of more value. In this study, data were collected from one center. To ensure the models’ generalizability, collecting data from different centers and evaluating model performance across different centers is necessary. As RFE only benefited from the RF model, it is possible that the features selected may not be the most optimal choice for other classifiers.The ED-MRMR-XGB has presented promising and acceptable results among ML algorithms. According to the results of the echo images, the individuals in the study had the same conditions (LVEF > 55%), but they were different based on the CMRI results, which were labeled accordingly, and then using the radiomic features extracted from the echo images and ML approaches were classified. Although the results of LVEF from echo were similar, by using the radiomic features extracted from these images, our models obtained promising results, which indicate that with non-invasive, inexpensive, portable, and highly accessible echocardiography, it is possible to identify who is prone to suffer from heart problems caused by iron overload in the near future and this can lead to a proper treatment to prevent cardiac problems and death of these patients. Therefore, early diagnosis of heart failure, even before the appearance of symptoms, has been made possible by radiomics of echo images and ML.Supplementary file1 (DOCX 2040 KB)Below is the link to the electronic supplementary material.


The most performed percutaneous valve replacement procedure is for the aortic valve. In recent years, there have been developments in percutaneous valve replacement methods for other valves, including the pulmonary valve. Computed tomography plays a crucial role in various stages of procedure planning and provides essential information regarding potential complications after the procedure. We present images documenting step by step how to evaluate cardiac computed tomography in the qualification procedure for transcatheter pulmonary valve implantation in patients with dysfunctional native right ventricular outflow tract. In cases of pathological heart valve conditions, the standard treatment method is valve replacement. Valve replacement can be performed surgically or through a less invasive percutaneous approach. The most commonly performed percutaneous valve replacement procedure is for the aortic valve. In recent years, there have been developments in percutaneous valve replacement methods for other valves, including the pulmonary valve .The primary indication for transcatheter pulmonary valve implantation (TPVI) is to treat dysfunction of the right ventricular outflow tract (RVOT) in patients who have undergone surgery for congenital heart defects, with the goal of preventing irreversible damage to the right ventricle (RV). Initially, TPVI was an alternative to surgery and was primarily used in patients with dysfunctional conduits connecting the right ventricle to the pulmonary artery (RV-PA conduit). However, it is now also used in patients with dysfunctional native RVOT, which has expanded the pool of eligible cases ,3. CompuBefore TPVI, CT imaging helps in patient selection, identifying contraindications to the procedure, and choosing the appropriate device. CT images are used to assess the morphology of the RVOT and the anatomy of the main pulmonary artery (MPA) ,5.To reduce artifacts and optimize image quality, a three-phase administration of contrast medium is used. Three-phase contrast agent administration involves the administration of: contrast agent alone, a mixture of contrast agent and physiological saline, and physiological saline only. Optimization of the ionizing radiation dose in this type of examination is particularly important. The methods that reduce the dose of ionizing radiation include CT tube voltage reduction, ECG-monitored radiation modulation (tube current), iterative image reconstruction, deep learning-based image reconstruction and deep learning-based image denoising, reduction in the scan range (scan length), modulation of the current intensity depends on the attenuation of the radiation, heart rate control, multi-slice, and dual-source and wide-field tomography. Retrospective ECG-gated CT facilitates dynamic assessment of the RVOT and pulmonary valve in all phases of the cardiac cycle, as well as quantitative evaluation of heart chamber volumes .The first piece of information obtained from CT images is the shape of the RVOT, which can take five different forms. Type I  is pyramidal or aneurysmal , type IIDue to the high isotropic spatial resolution in all phases and planes of the heart, CT is the most suitable method for measuring the native RVOT. Images from double-oblique reconstructions of the RVOT and PA are used for this purpose. Implantation in the native RVOT is more challenging than in the RV-PA conduit due to its larger, variable, and dynamic geometry, as well as its unpredictable compliance. Therefore, a comprehensive assessment of the native RVOT is required to determine the appropriate valve bioprosthesis. Measurements of surface areas, circumferences, and diameters at six different levels from the RVOT to the PA bifurcation are needed ,6 Figur. DependiThese measurements can change by up to 50% during the cardiac cycle, so it is essential to perform measurements in the end-systolic phase when the RVOT and MPA are largest, atrioventricular valves are closed, and heart chamber volumes are smallest, as well as in the end-diastolic phase when the RVOT and MPA are smallest, and heart chamber volumes are largest ,6 Figur.Additionally, three measurements of distances between the RVOT, pulmonary valve, and MPA bifurcation are performed  Figure .Potential complication associated with TPVI is the compression of the coronary artery. The risk of coronary artery compression is assessed during the heart catheterization procedure by inflating a balloon in the RVOT. However, CT imaging before the procedure can also help estimate the risk of coronary artery compression. The assessment involves measuring the distance between the coronary arteries and the RVOT or conduit. A distance of less than 2 mm between the coronary arteries and the RVOT is considered to increase the risk of coronary artery compression after TPVI ,5,6 Fig.CT examination also provides an information about vascular access and potential non-cardiac contraindications to the procedure.