RPS 403 - Inflammation, immunometabolism and cardiac imaging

Author Block: A. Č. Petkovic, N. Menkovic, O. Petrovic, I. Bilbija, D. Stanisavljevic, S. Putnik, B. Ivanovic, R. Maksimović; Belgrade/RS
Purpose: Infective endocarditis (IE) is rare disease with high mortality rate and rising incidence, requiring timely and precise diagnosis in order to choose appropriate therapy. Imaging of morphologic lesions is integrative part of diagnosis. Artifacts and patient’s habitus make echocardiography difficult to visualize advanced-form IE. Cardiac computed tomography (CCT) constantly shows an additive diagnostic value due to high spatial resolution of cardiac anatomy. Joint application of both diagnostic tests improves overall sensitivity and specificity in diagnosing IE.
Methods or Background: Diagnostic study of 83 patients who satisfied category of definite and possible IE, based on modified Duke’s criteria 2015, was conducted at University Clinical Center of Serbia, between May 2013 and April 2023. Patients underwent transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and CCT. We analyzed valvular and paravalvular IE lesions in three imaging methods and compared them to surgical or autopsy findings. We calculated sensitivity, specificity, diagnostic accuracy, and positive and negative predictive value of imaging tests individually and jointly used.
Results or Findings: We examined 78 patients and analyzed 85 valves (70 native, 13 prosthetic, and 2 corrected due to Ozaki procedure, central shunt and 4 pacemaker leads). As single test, sensitivity and specificity of CCT, TTE, and TEE for valvular lesions were 91.6/20%, 65.5/57.9%, and 60/84%, and paravalvular lesions were 100/0%, 46/10.5%, and 14.7/100%. When combined together, sensitivity and specificity for valvular lesions rose to 96.6/0% and paravalvular lesions to 100/0%. We also analyzed the diagnostic performance for each test in single and mutual application, per specific IE lesion.
Conclusion: CCT in comparison to TTE and TEE shows better diagnostic performance in detection of valvular and paravalvular lesions. In joint application, there is a statistically significant difference in performance compared to their single use.
Limitations: Not applicable.
Funding for this study: No funding was provided for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Ethics Committee of the School of Medicine of the University of Belgrade (No: 17/IV-26, 11 April 2023, Belgrade, Serbia)

Author Block: C. Martini, M. Covani, F. L. Gurgoglione, M. Della Bella, G. Cicala, L. Vignali, M. De Filippo, G. Niccoli, E. Solinas; Parma/IT
Purpose: To evaluate whether pericoronary adipose tissue (PCAT) attenuation, a marker of vascular inflammation, differs according to the type of trigger (emotional vs. physical) in patients with spontaneous coronary artery dissection (SCAD), and to explore the potential link between emotional stress, vascular inflammation, and SCAD pathophysiology.
Methods or Background: Inflammation may play a pivotal role in predisposing vascular fragility to spontaneous coronary artery dissection (SCAD). PCAT attenuation, derived from coronary computed tomography angiography (CCTA), is a recognized imaging biomarker of coronary inflammation. This analysis, part of the INSIDE-SCAD study, included patients with SCAD who underwent CCTA within 24 hours of the index event and had a clearly identifiable trigger. Patients were stratified by trigger type (emotional vs. physical). PCAT attenuation was measured in culprit and non-culprit vessels.
Results or Findings: Twenty-five SCAD patients were included (mean age 55±11 years; 80% female). Emotional triggers were reported in 17 patients (68%), and physical triggers in 8 (32%). Obesity was more prevalent in patients with physical triggers (62.5% vs. 5.9%, p=0.010), while Type 2 dissections were more frequent in the emotional trigger group (64.7% vs. 25.0%, p=0.040). Patients with emotional triggers exhibited significantly higher PCAT attenuation compared to those with physical triggers in the culprit vessel (−61.6 vs. −70.9 HU, p=0.019), LAD (−59.7 vs. −70.0 HU, p=0.023), and RCA (−66.7 vs. −75.4 HU, p=0.005).
Conclusion: Patients with SCAD showed elevated PCAT attenuation, particularly in cases associated with emotional triggers. These findings suggest that vascular inflammation may represent a predisposing factor for SCAD and that autonomic dysregulation may contribute to this inflammatory state.
Limitations: - Small sample size
- Observational sub-study design
- Selection bias (trigger-defined inclusion)
- Absence of a control group
- Lack of follow-up and outcome data
Funding for this study: Nothing to disclose
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Protocol number of approval by the Ethics Committee of the University Hospital of Parma (AOUPR): 605/2023/OSS/AOUPR SIRER ID 6728

Author Block: Y. Wang, M. Lu; Beijing/CN
Purpose: To externally validate the myocarditis risk stratification proposed in the 2025 European Society of Cardiology (ESC) guideline. A further aim was to determine whether cardiovascular magnetic resonance (CMR) parameters, specifically replacing late gadolinium enhancement (LGE) segment count with quantitative LGE extent and adding extracellular volume (ECV), could improve prognostic discrimination. The feasibility of a CMR-only risk stratification approach was also evaluated.
Methods or Background: We retrospectively included 308 patients with CMR-diagnosed acute myocarditis. We compared: (a) the original ESC 2025 three-tier model; (b) Model 1, substituting LGE extent for LGE segment count (threshold ≥9.5%, ROC-derived); (c) Model 2, adding ECV (threshold ≥37.5%) to refine low/intermediate risk; and (d) Model 3, a CMR-only three-tier scheme using ESC-defined LVEF categories together with dichotomized LGE extent and ECV. Risk discrimination was assessed by Kaplan–Meier analysis and Cox regression.
Results or Findings: A total of 55 major adverse cardiac events (17.9%) were observed during a median follow-up of 3.0 years. In the original ESC 2025 model, high-risk patients were effectively identified (HR 7.26, p=0.006), but intermediate vs. low risk was not significant (HR 1.79, p=0.467). In Model 1, both intermediate (HR 4.53, p=0.046) and high-risk groups (HR 16.93, p<0.001) were significantly different from low risk. In Model 2, prognostic separation further improved (intermediate HR 6.55, p=0.013; high HR 20.83, p<0.001). In Model 3 (CMR-only), risk stratification remained robust (intermediate HR 3.92, p=0.002; high HR 14.11, p<0.001). Model 2 achieved the highest C-index (0.787).
Conclusion: While the ESC 2025 scheme reliably identifies high-risk patients with myocarditis, quantitative LGE extent and ECV provide meaningful incremental value for distinguishing low and intermediate risk. A CMR-only stratification is feasible and shows robust prognostic separation.
Limitations: Single-center retrospective design; potential variability in CMR acquisition and analysis.
Funding for this study: This work was supported by The Construction Research Project of the Key Laboratory (Cultivation) of Chinese Academy of Medical Sciences (2019PT310025); National Natural Science Foundation of China (82471973); Noncommunicable Chronic Diseases-National Science and Technology Major Project (2023ZD0504502); Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences (CIFMS, 2021-I2M-1-063); Clinical and Translational Fund of Chinese Academy of Medical Sciences (2019XK320063); Youth Key Program of High-level Hospital Clinical Research (2022-GSP-QZ-5).
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The study was approved by the ethics committee of our Hospital (no. 2022–1770)

Author Block: L. R. M. Lanzafame, D. Masi, G. Ascenti, S. Mazziotti, T. D'Angelo; Messina/IT
Purpose: To evaluate the diagnostic performance of iodine maps generated from dual-layer spectral CT in detecting pericarditis.
Methods or Background: Patients with and without pericardial effusion who underwent coronary computed tomography angiography (CCTA) between February 2023 and December 2024 using a dual-layer spectral CT scanner were retrospectively enrolled. Regions of interest (ROIs) were positioned on the pericardial layers in the iodine maps to quantify iodine concentration (mg/mL). Furthermore, pericardial thickness was measured in both spectral and conventional reconstructions. Pericardial thickness was assessed in both spectral and conventional reconstructions. The diagnostic accuracy of iodine concentration and pericardial thickness in identifying pericarditis was assessed using the European Society of Cardiology (ESC) clinical criteria as reference standard.
Results or Findings: The study included 105 patients. The median iodine concentration in patients with pericarditis was 1.79 mg/mL [IQR:1.11–2.24], significantly higher than in negative patients (0.55 mg/mL [IQR:0.42–0.66]; p<0.0001). On conventional reconstructions pericardial thickness was 3.5 mm [IQR:2.7–4.2] in positive patients and 1.2 mm [IQR:1.15–1.3] in negative patients (p<0.0001). On iodine maps, corresponding values were 2.7 mm [IQR: 2.3–3.7] and 1.2 mm [IQR:1.1–1.3] (p<0.0001). Iodine maps achieved an AUC of 0.99 (95%CI:0.94–0.99), with 93.9% sensitivity (95%CI:79.8–99.3) and 95.8% (95%CI: 88.3–99.1) specificity, for a threshold of iodine concentration >0.82 mg/mL. For a pericardial thickness >1.6 mm, iodine maps showed an AUC of 1.00 (95%CI:0.97–1.00), with 100% sensitivity (95%CI:89.4–100) and 100% specificity (95%CI:95.0–100). Conventional reconstructions demonstrated an AUC of 1.00 (95%CI:0.95–1.00), with 100% sensitivity (95%CI:89.4–100) and 100% specificity (95%CI:90.5–100) in case of pericardial thickness >1.8 mm.
Conclusion: Spectral iodine maps demonstrated excellent diagnostic accuracy in detecting pericarditis based on iodine concentration and pericardial thickness.
Limitations: Retrospective, single-center design with modest sample size, exclusive use of dual-layer spectral CT.
Funding for this study: This research received no external funding.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: CT-OPTIMUM (Protocol No. 79-23)

Author Block: C. Lisi¹, F. Catapano¹, S. Figliozzi¹, L. S. Politi¹, A. Laghi¹, M. Francone²; ¹Milan/IT, ²Rome/IT
Purpose: To compare ultra-high-resolution photon-counting CT (UHR-PCD-CT) with energy-integrating detector CT (EID-CT) and standard-resolution PCD-CT for intra-individual evaluation of coronary stent patency.
Methods or Background: This prospective single-center study enrolled 51 patients (mean age, 64.5 ± 9.2 years; 16 women) with 67 coronary stents between November 2024 and April 2025. Patients were randomized to EID-CT plus coronary CT perfusion (n=26; 31 stents) or EID-CT plus UHR-PCD-CT (n=25; 36 stents). Image quality, diagnostic confidence, blooming index, and lumen diameters were compared among EID-CT, standard-resolution (SR) PCD-CT, and UHR-PCD-CT. In-stent restenosis (ISR) was defined as ≥50% stenosis and/or inducible ischemia. Radiation exposure was recorded. Statistical analyses included chi-square, t-test, Mann–Whitney U, and Cohen’s κ.
Results or Findings: Subjective image quality rated “excellent” was higher with UHR-PCD-CT (88.9%) vs SR-PCD-CT (45.2%, p<0.001) and EID-CT (22.6%, p<0.001). Internal lumen diameter was significantly larger with UHR-PCD-CT (2.65 ± 0.30 mm) vs SR-PCD-CT (2.40 ± 0.32 mm, p<0.01) and EID-CT (2.13 ± 0.36 mm, p<0.0001). Blooming artifacts decreased from 55.3% (EID-CT) and 42.8% (SR-PCD-CT) to 29.5% with UHR-PCD-CT (p<0.0001). Good/excellent diagnostic confidence (Likert 3–4) was achieved in 94.4% of UHR-PCD-CT stents vs 61.1% (SR-PCD-CT, p<0.001) and 41.9% (EID-CT, p<0.001). All stents <3 mm were assessable with UHR-PCD-CT vs 65% with EID-CT. Radiation dose of UHR-PCD-CT (12.0 ± 2.8 mSv) was comparable to EID-CT plus CTP (11.5 ± 2.5 mSv; p=0.42).
Conclusion: UHR-PCD-CT markedly improves lumen visualization, reduces blooming artifacts, and increases diagnostic confidence in coronary stent evaluation, particularly for stents <3 mm, with radiation exposure comparable to combined EID-CT and CT perfusion.
Limitations: Single-center design and modest sample size. Lack of systematic invasive coronary angiography validation and of long-term clinical outcomes.
Funding for this study: No funding, but this work was funded by the National Plan for NRRP Complementary Investments (PNC, established with the decree-law 6 May 2021, n. 59, converted by law n. 101 of 2021) in the call for the funding of research initiatives for technologies and innovative trajectories in the health and care sectors (Directorial Decree n. 931 of 06-06-2022) - project n. PNC0000003 - AdvaNced Technologies for Human-centrEd Medicine (project acronym: ANTHEM). This work reflects only the authors’ views and opinions, neither the Ministry for University and Research nor the European Commission can be considered responsible for them.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:

Author Block: J. M. Brendel¹, T. Mayrhofer¹, N. Kerkovits¹, S. Ersözlü¹, M. Kolossvary², M. T. Lu¹, M. Ferencik³, P. Douglas⁴, B. Foldyna¹; ¹Boston, MA/US, ²Budapest/HU, ³Portland/US, ⁴Durham/US
Purpose: To investigate whether HS is related to plaque volume, plaque burden, and MACE, and whether coronary plaque composition mediates the relationship between HS and MACE.
Methods or Background: Hepatic steatosis (HS) has been linked to major adverse cardiovascular events (MACE) independently of other cardiovascular risk factors and the extent of coronary artery disease. However, the association between HS, advanced plaque measures, and MACE remains unclear.

A central core laboratory analyzed PROMISE participants randomized to the CT arm. HS was assessed on non-contrast CT using standard hepatic and splenic attenuation methods. Coronary CT angiography was used to quantify total, calcified, noncalcified, and low-attenuation plaque volume and burden (% vessel volume). Multivariable regression and mediation analyses assessed relationships between HS, plaque components, and MACE (death, myocardial infarction, unstable angina hospitalization; median follow-up 25 months, IQR: 18–33).
Results or Findings: Among 3,637 patients (60.6±8.2 years, 51.4% female), 25.5% had HS and were slightly younger, more often male, had more cardiovascular risk factors, and a higher MACE rate (4.1% vs. 2.5%), all p<0.05. After adjustment for clinical risk factors, HS was associated exclusively with greater noncalcified plaque burden (NCPB, β 1.25%; 95%CI 0.02–2.49; p=0.047). HS conferred increased MACE risk independent of atherosclerotic cardiovascular disease risk score, obesity, obstructive stenosis, and NCPB (aHR 1.69; 95%CI, 1.12–2.54; p=0.012). NCPB accounted for 11% of the association between HS and MACE.
Conclusion: HS is linked to greater NCPB and to MACE, independent of clinical risk factors and advanced CT plaque measures. HS should be considered when stratifying cardiovascular risk and may inform medical therapy.
Limitations: Median follow-up of just over 2 years limits the ability to assess long-term outcomes.
Funding for this study: This study was supported by NIH/NHLBI grants #1R01HL098236, #1R01HL098237, #1R01HL098305, #1R01HL170877-01, #1R01HL146145-01A1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: All participants provided written informed consent, and the trial was approved by local or central institutional review boards (ClinicalTrials.gov NCT01174550)

Author Block: L. J. Moser¹, T. T. Demmert¹, K. Klambauer¹, V. Mergen¹, B. Stähli², R. Manka¹, M. Eberhard¹, C. Templin³, H. Alkadhi¹; ¹Zürich/CH, ²Zurich/CH, ³Greifswald/DE
Purpose: The purpose of this study was to evaluate the performance of coronary CTA for the diagnosis of acute SCAD.
Methods or Background: This prospective single-center study included 52 patients with SCAD confirmed by invasive coronary angiography (ICA) and 70 patients with chest pain but without SCAD (control group), who all underwent coronary CTA. Two independent readers evaluated coronary CTA for SCAD, including vessel abnormalities and myocardial hypodensity. Accuracy, sensitivity, and specificity with 95% confidence intervals (CI) were calculated using ICA as the reference standard. Coronary CTA imaging features of SCAD were correlated with diagnostic confidence using multivariable regression analysis. Interreader agreement was determined by Cohen’s Kappa.
Results or Findings: Patient-level sensitivity of coronary CTA to diagnose SCAD ranged from 52% (CI:38%-66%)-58% (CI:43%-71%), with a specificity of 97% (CI:90%-100%) and accuracy of 78% (CI:69%-85%) and 80% (CI:72%-87%) for both readers (Kappa=0.891). Sensitivity and accuracy were higher for proximal (sensitivity 67% (CI:38%-88%) and 73% (CI:45%-92%); accuracy 93% (CI:87%-97%) and 94% (CI:89%-98%)) than for distal SCAD (sensitivity 40% (CI:26%-56%) and 49% (CI:34%-64%); accuracy 76% (CI:68%-83%) and 80% (CI:71%-86%)), while specificity was high irrespective of location (97%; CI:91%-99%, resp.100%). Additional myocardial hypodensity increased readers’ confidence (beta coefficient -0.38; p=0.11 for reader 1, and beta coefficient of -0.90; p=0.004 for reader 2) and sensitivity (71% (CI:57%-83%) and 65% (CI:51%-78%), respectively), while reducing specificity (both 91%, CI:82%-97%).
Conclusion: Coronary CTA has a poor sensitivity for the diagnosis of SCAD, while specificity is high irrespective of SCAD location. Patients with coronary CTA positive for SCAD might be deferred from ICA after careful consideration and when conservative management is intended.
Limitations: The limitations of the study are as follows: Single center study. Different generations of CT scanners. Not all patients in the control cohort underwent ICA.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Approval by local ethics committee.

Author Block: Z. Zhou, L-y. Wen, S. Azhe, L. Hu, Y. Zhu; Chengdu/CN
Purpose: To evaluate the role of CMR-derived Left Atrial (LA) strain in prognostic assessment in patients with Kawasaki disease (KD) and to investigate their incremental value beyond coronary artery lesions and late gadolinium enhancement (LGE).
Methods or Background: The prospective study analyzed 214 KD patients (median age, 5.5 years [IQR, 3.4-7.7 years]; 142 male) who under CMR examination. Clinical composite endpoint events included cardiac death, decreased left ventricular systolic function, cardiac cerebral ischemic syndrome, syncope, readmission for treatment due to chest pain, and malignant arrhythmias. Cox survival analysis was used to assess the association between variables and time to the end points. C index and chi-square value were used to determine the incremental value of LA strain.
Results or Findings: During a median follow-up of 32.1 months (IQR, 20.2–46.3 months), 33 of 214 (15.4%) patients experienced clinical composite endpoint events. Multivariable Cox regression analysis of Model 1 (including coronary thrombosis and LGE positive), revealed that both soronary thrombosis (HR: 3.007; 95% CI: 1.114–8.121; P = 0.03) and LGE positive (HR: 4.104; 95% CI: 1.471–11.453; P = 0.007) were independent predictors for the clinical composite endpoint. Multivariate Cox regression of Model 2 (including Model 1 and εe), showed that εe was independent predictors of the clinical composite endpoint events (HR: 0.972; 95%CI: 0.945–0.999, P=0.042). Compared with Model 1, Model 2 showed a significantly higher chi-square value (57.36 vs. 52.46, P<0.001) and C index (0.73 vs. 0.66, P<0.001).
Conclusion: εe was the independent predictor of clinical composite endpoint events. Moreover, εe provides incremental value to coronary thrombosis and LGE positive in predicting clinical composite endpoint events.
Limitations: The primary limitation of this study is its small single-center sample size.
Funding for this study: This work was supported by the National Natural Science Foundation of China (82471970), Sichuan Science and Technology Program (2024YFFK0258).
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The ethics was approved by the Ethics committee of West China Second University Hospital.

Author Block: T. R. Readford¹, M. Ugander², P. Kench¹, G. Figtree¹, J. Nadel¹, N. Giannotti¹; ¹Sydney/AU, ²Solna/SE
Purpose: Contemporary strategies for detection and management of atherosclerosis focus on controlling Standard Modifiable Risk Factors (SMuRFs) including diabetes, hypertension, hyperlipidaemia, and smoking. However, it is unclear if extracardiac thoracoabdominal atherosclerotic plaque burden is associated with SMuRFs.

The purpose of this study was to compare extracardiac thoracoabdominal atherosclerotic plaque burden by computed tomography angiography (CTA) between patients with and without SMuRFs among heart transplant candidates with ischaemic or non-ischaemic cardiomyopathy (ICM, NICM).
Methods or Background: This study was a retrospective, single-centre observational study. Heart transplant candidates with ICM or NICM undergoing thoracoabdominal CTA were matched for age and sex. Patients were classified as those with SMuRFs or SMuRF-less based on medical records. Extracardiac thoracoabdominal non-calcified and calcified plaque was classified as present or absent across 80 arterial segments per patient.
Results or Findings: Among included patients (n=167, median [interquartile range] age 58 [53-63] years, 16% female, 51% NICM), 40 patients (24%) were SMuRF-less (ICM: 16/82 (20%), NICM: 24/85 (28%), age 56 [50-67] years). Overall, out of 13,360 arterial segments, 1,746 (13%) were affected by atherosclerotic plaque (9 [4-15] segments per patient). Compared to NICM, ICM had higher total plaque burden (11 [7-18] vs 6 [3-11] segments per patient, p<0.001). However, SMuRF-less patients showed no difference in non-calcified, calcified, and total plaque burden compared to patients with SMuRFs among all patients (ICM+NICM) (p>0.17 for all), and within the ICM and NICM groups, respectively (p>0.30 for all).
Conclusion: The burden of extracardiac thoracoabdominal atherosclerotic plaque does not differ among heart transplant candidates that are SMuRF-less or those with SMuRFs, regardless of underlying ICM or NICM. Prevalence of SMuRFs is not an effective marker to determine the need to screen for extracardiac atherosclerotic plaque among heart transplant candidates.
Limitations: Retrospective observational design.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This study was approved by the local human subject research ethics committee with a retrospective waiver of individual informed consent.