Background: Myocardial injury, defined by elevated troponin levels, is associated with adverse outcome in patients with coronavirus disease 2019 (COVID-19). The frequency of cardiac injury remains highly uncertain and confounded in current publications; myocarditis is one of several mechanisms that have been proposed. Methods: We prospectively assessed patients with myocardial injury hospitalized for COVID-19 using transthoracic echocardiography, cardiac magnetic resonance imaging, and endomyocardial biopsy. Results: Eighteen patients with COVID-19 and myocardial injury were included in this study. Echocardiography revealed normal to mildly reduced left ventricular ejection fraction of 52.5% (46.5%–60.5%) but moderately to severely reduced left ventricular global longitudinal strain of −11.2% (−7.6% to −15.1%). Cardiac magnetic resonance showed any myocardial tissue injury defined by elevated T1, extracellular volume, or late gadolinium enhancement with a nonischemic pattern in 16 patients (83.3%). Seven patients (38.9%) demonstrated myocardial edema in addition to tissue injury fulfilling the Lake-Louise criteria for myocarditis. Combining cardiac magnetic resonance with speckle tracking echocardiography demonstrated functional or morphological cardiac changes in 100% of investigated patients. Endomyocardial biopsy was conducted in 5 patients and revealed enhanced macrophage numbers in all 5 patients in addition to lymphocytic myocarditis in 1 patient. SARS-CoV-2 RNA was not detected in any biopsy by quantitative real-time polymerase chain reaction. Finally, follow-up measurements of left ventricular global longitudinal strain revealed significant improvement after a median of 52.0 days (−11.2% [−9.2% to −14.7%] versus −15.6% [−12.5% to −19.6%] at follow-up; P =0.041). Conclusions: In this small cohort of COVID-19 patients with elevated troponin levels, myocardial injury was evidenced by reduced echocardiographic left ventricular strain, myocarditis patterns on cardiac magnetic resonance, and enhanced macrophage numbers but not predominantly lymphocytic myocarditis in endomyocardial biopsies.

Background: Microvascular obstruction (MVO) at cardiac magnetic resonance imaging (CMR) is a well-described risk factor for cardiac events after acute myocardial infarction (MI). Objective: Predicting MVO using cardiac biomarkers and performing risk stratification according to extent of MVO. Methods: We conducted a retrospective study including all patients with an acute MI and a subsequent CMR during the same hospital stay between October 2008 and August 2023. Patients were grouped according to the presence of any MVO and of relevant MVO (defined as > 1.55% of LV myocardial mass). The prediction of MVO based on peak high sensitivity cardiac troponin T (hs-cTnT) levels was analyzed. Survival according to MVO status was assessed in the entire study population. Results: We evaluated 597 patients with CMR 3 days [interquartile range 2–4 days] after myocardial infarction. MVO was present in 163 patients (27.3%) and relevant MVO in 100 patients (16.8%). Patients with MVO had significantly higher peak hs-cTnT levels compared to those without (p < 0.001). An hs-cTnT cut-off value of > 2455.0 ng/L predicted present MVO (area under the curve (AUC) 0.824), while a cut-off value of 3975.0 ng/L predicted relevant MVO (AUC 0.837). Relevant MVO was a predictor of all-cause mortality in the entire study population (hazard ratio (HR) 3.89 (1.50–10.09)), with an even stronger association in patients with an LVEF > 35% (HR 5.91 (1.79–19.56)). Conclusion: Higher peak hs-cTnT levels are strong predictors of MVO. Described cut-off values could serve as a screening tool. Relevant MVO is a significant predictor of all-cause mortality following acute MI, especially in patients with LVEF > 35%. Graphical Central Illustration: Screening for and risk stratification based on MVO Legend: Screening for microvascular obstruction after myocardial infarction and risk stratification based on extent of microvascular obstruction at cardiovascular magnetic resonance.

Background/Objectives: The extent of myocardial scar, visualized by late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR), is associated with mortality after acute myocardial infarction (MI). However, data on optimal cardiac biomarker cut-off values (e.g., high-sensitivity cardiac troponin T, hs-cTnT) for predicting LGE remain limited. This study aimed to evaluate the predictive value of cardiac biomarkers for LGE and their influence on clinical outcomes. Methods: We included 597 patients who underwent CMR a median of 3 days [interquartile range (IQR) 2–4 days] after MI (407 STEMI and 190 NSTEMI patients), with a median follow-up period of 3.0 years [IQR 1.3–3.5 years]. Results: After adjusting for key variables, maximum cardiac biomarker levels were found to have the strongest correlation with the presence and extent of LGE (p < 0.001). LGE mass and LVEF were the most robust predictors of all-cause mortality (hazard ratio [CI] 1.464 [1.050–2.040], p = 0.025, Harrell’s C 0.812; 0.697 [0.491–0.990], p = 0.044, Harrell’s C 0.810, respectively). We determined a receiver operating characteristic (ROC) area under the curve (AUC) of 0.73 and an optimal cut-off of 53 g for LGE mass and mortality, with a maximum hs-cTnT cut-off of 7270 ng/L predicting this extent of LGE. Conclusions: In this large cohort of MI patients with three-year follow-up, cardiac biomarker levels showed a strong correlation with the extent of LGE. While absolute LGE mass was associated with mortality, its predictive value was comparable to that of CMR-derived LVEF. These findings should be interpreted cautiously, given the study’s observational design, and should be considered hypothesis-generating, underscoring the need for prospective validation.

Objectives: The aim of this study was to evaluate the influence of three-dimensional transcatheter heart valve (THV) position on mid-term pacing burdens and to examine the effect of stimulation rates on survival after transcatheter aortic valve implantation (TAVI). Methods: In patients receiving a new PPM before discharge after TAVI, we analyzed the final three-dimensional THV position in 107 patients (78 with Sapien S3 THV and 29 with Evolut R THV) using fusion imaging from pre- and post-TAVI computed tomography angiography. The PPM stimulation rates were examined pre-discharge and after 3 months. Patient survival was tracked over a period of 5 years. Results: A high pacing burden (stimulation rate of >20%) was observed in 69% of patients before discharge and in 67% after three months. One-third of the patients with an initial low pacing burden developed a high pacing burden after 3 months. The implantation depth did not differ between patients with or without a high pacing burden at discharge (p = 0.550) or after 3 months (p = 0.901). The three-dimensional THV position showed no influence on the pacing burden pre-discharge (p = 0.550) and after 3 months (0.901). There were no significant differences in survival, regardless of the pacing burden pre-discharge and after 3 months (log-rank p = 0.676). Conclusions: Three-dimensional THV position did not predict a high pacing burden after TAVI. Pacing burden was not associated with survival. One-third of patients experienced an increase to a high pacing burden within 3 months, suggesting potential long-term conduction system damage after TAVI.

Background: We aimed to evaluate the feasibility of a non-contrast time-of-flight magnetic resonance angiography (TOF-MRA) protocol for the pre-procedural access route assessment of transcatheter aortic valve implantation (TAVI) in comparison with contrast-enhanced cardiac dual-source computed tomography angiography (CTA). Methods and Results: In total, 51 consecutive patients (mean age: 82.69 ± 5.69 years) who had undergone a pre-TAVI cardiac CTA received TOF-MRA for a pre-procedural access route assessment. The MRA image quality was rated as very good (median of 5 [IQR 4–5] on a five-point Likert scale), with only four examinations rated as non-diagnostic. The TOF-MRA systematically underestimated the minimal effective vessel diameter in comparison with CTA (for the effective vessel diameter in mm, the right common iliac artery (CIA)/external iliac artery (EIA)/common femoral artery (CFA) MRA vs. CTA was 8.04 ± 1.46 vs. 8.37 ± 1.54 (p < 0.0001) and the left CIA/EIA/CFA MRA vs. CTA was 8.07 ± 1.32 vs. 8.28 ± 1.34 (p < 0.0001)). The absolute difference between the MRA and CTA was small (for the Bland–Altman analyses in mm, the right CIA/EIA/CFA was −0.36 ± 0.77 and the left CIA/EIA/CFA was −0.25 ± 0.61). The overall correlation between the MRA and CTA measurements was very good (with a Pearson correlation coefficient of 0.87 (p < 0.0001) for the right CIA/EIA/CFA and a Pearson correlation coefficient of 0.9 (p < 0.0001) for the left CIA/EIA/CFA). The feasibility agreement between the MRA and CTA for transfemoral access was good (the right CIA/EIA/CFA agreement was 97.9% and the left CIA/EIA/CFA agreement was 95.7%, Kohen’s kappa: 0.477 (p = 0.001)). Conclusions: The TOF-MRA protocol was feasible for the assessment of the access route in an all-comer pre-TAVI population. This protocol might be a reliable technique for patients at an increased risk of contrast-induced nephropathy.