To investigate the relationship between left ventricular (LV) long-axis strain (LAS) and LV sphericity index (LVSI) and outcomes in patients with nonischemic dilated cardiomyopathy (NIDCM) and myocardial replacement fibrosis confirmed by late gadolinium enhancement (LGE) using cardiac magnetic resonance imaging (cMRI), we conducted a prospective study on 178 patients (48 ± 14.4 years; 25.2% women) with first NIDCM diagnosis. The evaluation protocol included ECG monitoring, echocardiography and cMRI. LAS and LVSI were cMRI-determined. Major adverse cardiovascular events (MACEs) were defined as a composite outcome including heart failure (HF), ventricular arrhythmias (VAs) and sudden cardiac death (SCD). After a median follow-up of 17 months, patients with LGE+ had increased risk of MACEs. Kaplan-Meier curves showed significantly higher rate of MACEs in patients with LGE+ (p < 0.001), increased LVSI (p < 0.01) and decreased LAS (p < 0.001). In Cox analysis, LAS (HR = 1.32, 95%CI (1.54–9.14), p = 0.001), LVSI [HR = 1.17, 95%CI (1.45–7.19), p < 0.01] and LGE+ (HR = 1.77, 95%CI (2.79–12.51), p < 0.0001) were independent predictors for MACEs. In a 4-point risk scoring system based on LV ejection fraction (LVEF) < 30%, LGE+, LAS > −7.8% and LVSI > 0.48%, patients with 3 and 4 points had a significantly higher risk for MACEs. LAS and LVSI are independent predictors of MACEs and provide incremental value beyond LVEF and LGE+ in patients with NIDCM and myocardial fibrosis.

Background: Myocardial scarring is a primary pathogenetic process in nonischemic dilated cardiomyopathy (NIDCM) that is responsible for progressive cardiac remodeling and heart failure, severely impacting the survival of these patients. Although several collagen turnover biomarkers have been associated with myocardial fibrosis, their clinical utility is still limited. Late gadolinium enhancement (LGE) determined by cardiac magnetic resonance imaging (CMR) has become a feasible method to detect myocardial replacement fibrosis. We sought to evaluate the association between collagen turnover biomarkers and replacement myocardial scarring by CMR and, also, to test their ability to predict outcome in conjunction with LGE in patients with NIDCM. Method: We conducted a prospective study on 194 patients (48.7 ± 14.3 years of age; 74% male gender) with NIDCM. The inclusion criteria were similar to those for the definition of NIDCM, performed exclusively by CMR: (1) LV dilation with an LV end-diastolic volume (LVEDV) of over 97 mL/m²; (2) global LV dysfunction, expressed as a decreased LVEF of under 45%. CMR was used to determine the presence and extent of LGE. Several collagen turnover biomarkers were determined at diagnosis, comprising galectin-3 (Gal3), procollagen type I carboxy-terminal pro-peptide (PICP) and N-terminal pro-peptide of procollagen type III (PIIINP). A composite outcome (all-cause mortality, ventricular tachyarrhythmias, heart failure hospitalization) was ascertained over a median of 26 months. Results: Gal3, PICP and PIIINP were considerably increased in those with LGE+ (p < 0.001), also being directly correlated with LGE mass (r² = 0.42; r² = 0.44; r² = 0.31; all p < 0.001). Receiver operating characteristic (ROC) analysis revealed a significant ability to diagnose LGE, with an area under the ROC of 0.816 for Gal3, 0.705 for PICP, and 0.757 for PIIINP (all p < 0.0001). Kaplan–Meier analysis showed that at a threshold of >13.8 ng/dL for Gal3 and >97 ng/dL for PICP, they were able to significantly predict outcome (HR = 2.66, p < 0.001; HR = 1.93, p < 0.002). Of all patients, 17% (n = 33) reached the outcome. In multivariate analysis, after adjustment for covariates, only LGE+ and Gal3+ remained independent predictors for outcome (p = 0.008; p = 0.04). Nonetheless, collagen turnover biomarkers were closely related to HF severity, providing incremental predictive value for severely decreased LVEF of under 30% in patients with NIDCM, beyond that with LGE alone. Conclusions: In patients with NIDCM, circulating collagen turnover biomarkers such as Gal3, PICP and PIIINP are closely related to the presence and extent of LGE and can significantly predict cardiovascular outcome. The joint use of LGE with Gal3 and PICP significantly improved outcome prediction.

Left atrial (LA) geometry and phasic functions are frequently impaired in non-ischaemic dilated cardiomyopathy (NIDCM). Cardiac magnetic resonance (CMR) can accurately measure LA function and geometry parameters. We sought to investigate their prognostic role in patients with NIDCM. We prospectively examined 212 patients with NIDCM (49 ± 14.2-year-old; 73.5% males) and 106 healthy controls. LA volumes, phasic functions, geometry, and fibrosis were determined using CMR. A composite outcome (cardiac death, ventricular tachyarrhythmias, heart failure hospitalization) was ascertained over a median of 26 months. LA phasic functions, sphericity index (LASI) and late gadolinium enhancement (LA-LGE) were considerably impaired in the diseased group (p < 0.001) and significantly correlated with impaired LV function parameters (p < 0.0001). After multivariate analysis, LA volumes, LASI, LA total strain (LA-ε_t) and LA-LGE were associated with increased risk of composite outcome (p < 0.001). Kaplan–Meier analysis showed significantly higher risk of composite endpoint for LA volumes (all p < 0.01), LASI > 0.725 (p < 0.003), and LA-ε_t < 30% (p < 0.0001). Stepwise Cox proportional-hazards models demonstrated a considerable incremental predictive value which resulted by adding LASI to LA-ε_t (Chi-square = 10.2, p < 0.001), and afterwards LA-LGE (Chi-Square = 15.8; p < 0.0001). NIDCM patients with defective LA volumes, LASI, LA-LGE and LA-ε_t had a higher risk for an outcome. LA-ε_t, LASI and LA-LGE provided independent incremental predictive value for outcome.

Pulmonary hypertension (PH) is a life-threatening cardiopulmonary disease associated with a poor prognosis, with progressive right ventricular (RV) failure being the main cause of death in this vulnerable population. Right heart catheterization remains the gold standard for assessing pulmonary hemodynamics. However, due to its invasive nature, non-invasive imaging methods are gaining increasing interest. Two-dimensional transthoracic echocardiography serves as the primary screening tool for PH and is widely used to estimate its likelihood. Nevertheless, this technique has several limitations, partially addressed through the assistance of a three-dimensional echocardiography. Cardiac magnetic resonance imaging (CMR) provides a comprehensive evaluation of both the morphology and hemodynamics of right ventricle-pulmonary artery unit, offering essential information for diagnosis, prognosis, and therapeutic monitoring. While two-dimensional cardiac CMR enables non-invasive characterization of pulmonary hemodynamics, advances in 4D-flow cardiac CMR allow for a more detailed analysis. These advancements enable the assessment of flow patterns, energetics, wall shear stress and severity, offering a more nuanced understanding of the disease. This review aims to provide an in-depth summary of the current data on advanced non-invasive imaging techniques for PH.

Objectives: The presence of a bicuspid aortic valve (BAV) is known to alter transvalvular flow and increase shear stress on the ascending aorta, contributing to alterations in aortic geometry and the progression of BAV-related aortopathy. The purpose of the current study was to characterize aortic flow abnormalities and their associations with aortic geometry and ventricular mechanics using cardiac magnetic resonance imaging (CMR). Methods: In this prospective cross-sectional study, 56 young adults with CMR-confirmed BAV and 56 age- and sex-matched healthy volunteers underwent standardized CMR. Biventricular volumes and function, LV global longitudinal strain (LV-GLS), LV torsional mechanics, ascending aortic geometry, pulse-wave velocity, aortic distensibility, and two-dimensional phase-contrast-derived forward and backward flow parameters were quantified. Associations between myocardial mechanics and haemodynamic variables were assessed using correlation analyses and multivariable linear regression. Results: Compared with healthy controls, patients with BAV exhibited preserved LV ejection fraction but impaired LV-GLS, reduced LV torsion, increased aortic stiffness, and a significantly greater backward-flow burden despite similar net aortic flow (all p < 0.001). Higher peak backward-to-forward flow-rate ratios were associated with less negative LV-GLS (p = 0.006), whereas greater aortic regurgitant volume was also associated with impaired longitudinal deformation (p = 0.001). In multivariable analysis, LV-GLS and aortic regurgitant volume remained associated with the peak backward-to-forward flow-rate ratio within the specified model, whereas ascending-aortic dimensions were not. The final model explained 52% of the variability in backward-flow burden. Conclusions: CMR identified a subclinical ventricular-aortic phenotype in young adults with BAV characterized by altered LV mechanics, increased aortic stiffness, and greater relative backward-flow burden despite preserved conventional LV systolic function. The association between backward-flow burden and LV longitudinal mechanics suggests that these abnormalities may represent interrelated manifestations of BAV disease; however, their temporal and causal relationships cannot be established from this cross-sectional study.