Word count: 4478words (including figures legends and references)Running title: Prognostic role of CMR and conventional risk factors in MINOCA Abstract: Objective: Assess the prognostic impact of Cardiovascular Magnetic Resonance (CMR) and conventional risk factors in patients with Myocardial infarction with non-obstructed coronaries (MINOCA). Background: MINOCA represents a diagnostic dilemma and the prognostic markers have not been clarified. Methods: 388 consecutive MINOCA patients undergoing CMR assessment were identified retrospectively from registry database and prospectively followed up for a primary clinical endpoint of all-cause mortality. 1.5T CMR was performed using a comprehensive protocol (cines, T2-weighted, and late gadolinium enhancement sequences). Patients were grouped into 4 categories based on their CMR findings: myocardial infarction (MI) (embolic/spontaneous recanalization), myocarditis, cardiomyopathy and normal CMR. Results: CMR(performed at a median of 37days from presentation) was able to identify the cause for the troponin rise in 74% of the patients (25% myocarditis, 25% MI and 25% cardiomyopathy), whilst a normal CMR was identified in 26%. Over a median follow-up of 1262days(3.5years), 5.7% patients died. Cardiomyopathy group had the worst prognosis (mortality 15%, log rank 19.9 p<0.001), MI had 4% mortality, and 2% in both myocarditis and normal CMR. In a multivariable cox regression model (including clinical and CMR parameters), CMR diagnosis of cardiomyopathy and ST-segment elevation on presentation ECG remained the only 2 significant predictors of mortality. Using presentation with ECG ST-elevation and CMR diagnosis of cardiomyopathy as risk markers, the mortality risk rates were 2%, 11% and 21% for presence of 0, 1 and 2 factor respectively(p<0.0001). Conclusion: In a large cohort of MINOCA, CMR(median 37days from presentation) identified a final diagnosis in 74% of patients. Cardiomyopathy had the highest mortality, followed by MI. The strongest predictors of mortality were a CMR diagnosis of cardiomyopathy and ST-elevation on presentation ECG.

OBJECTIVES This study aimed to explore aortic morphology and the associations between morphological features and cardiovascular function in a population of patients with bicuspid aortic valve, while further assessing differences between patients with repaired coarctation, patients with unrepaired coarctation and patients without coarctation. METHODS This is a single-centre retrospective study that included patients with available cardiovascular magnetic resonance imaging data and native bicuspid aortic valve diagnosis ( n = 525). A statistical shape analysis was performed on patients with a 3-dimensional magnetic imaging resonance (MRI) dataset ( n = 108), deriving 3-dimensional aortic reconstructions and computing a mean aortic shape (template) for the whole population as well as for the 3 subgroups of interest (no coarctation, repaired coarctation and unrepaired coarctation). Shape deformations (modes) were computed and correlated with demographic variables, 2-dimensional MRI measurements and volumetric and functional data. RESULTS Overall, the results showed that patients with coarctation tended towards a more Gothic arch architecture, with decreased ascending and increased descending aorta diameters, with the unrepaired-aortic coarctation subgroup exhibiting more ascending aorta dilation. Careful assessment of patients with repaired coarctation only revealed that a more Gothic arch, increased descending aorta dimensions and ascending aorta dilation were associated with reduced ejection fraction ( P ≤ 0.04), increased end-diastolic volume ( P ≤ 0.04) and increased ventricular mass ( P ≤ 0.02), with arch morphology distinguishing patients with and without recoarctation ( P = 0.05). CONCLUSIONS A statistical shape modelling framework was applied to a bicuspid aortic valve population revealing nuanced differences in arch morphology and demonstrating that morphological features, not immediately described by conventional measurements, can indicate those shape phenotypes associated with compromised function and thus possibly warranting closer follow-up.

et al. Current and future applications of 3D printing in congenital cardiology and cardiac surgery. Br J Radiol 2018; 91: 20180389.aBStract Three-dimensional (3D) printing technology in congenital cardiology and cardiac surgery has experienced a rapid development over the last decade. In presence of complex cardiac and extra-cardiac anatomies, the creation of a physical, patient-specific model is attractive to most clinicians. However, at the present time, there is still a lack of strong scientific evidence of the benefit of 3D models in clinical practice and only qualitative evaluation of the models has been used to investigate their clinical use. 3D models can be printed in rigid or flexible materials, and the original size can be augmented depending on the application the models are needed for. The most common applications of 3D models at present include procedural planning of complex surgical or interventional cases, in vitro simulation for research purposes, training and communication with patients and families. The aim of this pictorial review is to describe the basic principles of this technology and present its current and future applications.

Bicuspid aortic valve (BAV) patients have an increased incidence of developing aortic dilation. Despite its importance, the pathogenesis of aortopathy in BAV is still largely undetermined. Nowadays, intense focus falls both on BAV morphology and progression of valvular dysfunction and on the development of aortic dilation. However, less is known about the relationship between aortic valve morphology and aortic dilation. A better understanding of the molecular pathways involved in the homeostasis of the aortic wall, including the extracellular matrix, the plasticity of the vascular smooth cells, TGFβ signaling, and epigenetic dysregulation, is key to enlighten the mechanisms underpinning BAV-aortopathy development and progression. To date, there are two main theories on this subject, i.e., the genetic and the hemodynamic theory, with an ongoing debate over the pathogenesis of BAV-aortopathy. Furthermore, the lack of early detection biomarkers leads to challenges in the management of patients affected by BAV-aortopathy. Here, we critically review the current knowledge on the driving mechanisms of BAV-aortopathy together with the current clinical management and lack of available biomarkers allowing for early detection and better treatment optimization.

ObjectiveTo evaluate the feasibility of three-dimensional (3D) printing models of coronary artery anomalies based on cardiac CT data and explore their potential for clinical applications.DesignCardiac CT datasets of patients with various coronary artery anomalies (n=8) were retrospectively reviewed and processed, reconstructing detailed 3D models to be printed in-house with a desktop 3D printer (Form 2, Formlabs) using white resin.SettingA University Hospital (division of cardiology) in the UK.ParticipantsThe CT scans, first and then 3D-printed models were presented to groups of clinicians (n=8) and cardiovascular researchers (n=9).InterventionParticipants were asked to assess different features of the 3D models and to rate the models’ overall potential usefulness.Outcome measuresModels were rated according to clarity of anatomical detail, insight into the coronary abnormality, overall perceived usefulness and comparison to CT scans. Assessment of model characteristics used Likert-type questions (5-point scale from ‘strongly disagree’ to ‘strongly agree’) or a 10-point rating (from 0, lowest, to 10, highest). The questionnaire included a feedback form summarising overall usefulness. Participants’ imaging experience (in a number of years) was also recorded.ResultsAll models were reconstructed and printed successfully, with accurate details showing coronary anatomy (eg, anomalous coronary artery, coronary roofing or coronary aneurysm in a patient with Kawasaki syndrome). All clinicians and researchers provided feedback, with both groups finding the models helpful in displaying coronary artery anatomy and abnormalities, and complementary to viewing 3D CT scans. The clinicians’ group, who had substantially more imaging expertise, provided more enthusiastic ratings in terms of models’ clarity, usefulness and future use on average.Conclusions3D-printed heart models can be feasibly used to recreate coronary artery anatomy and enhance understanding of coronary abnormalities. Future studies can evaluate their cost-effectiveness, as well as potentially explore other printing techniques and materials.

3D models have been used as an asset in many clinical applications and a variety of disciplines, and yet the available literature studying the use of 3D models in communication is limited. This scoping review has been conducted to draw conclusions on the current evidence and learn from previous studies, using this knowledge to inform future work. Our search strategy revealed 269 papers, 19 of which were selected for final inclusion and analysis. When assessing the use of 3D models in doctor–patient communication, there is a need for larger studies and studies including a long-term follow up. Furthermore, there are forms of communication that are yet to be researched and provide a niche that may be beneficial to explore.

3D printing has recently become an affordable means of producing bespoke models and parts. This has now been extended to models produced from medical imaging, such as computed tomography (CT). Here we report the production of a selection of 3D models to compliment the available imaging data for a 12-month-old child with double-outlet right ventricle and two ventricular septal defects. The models were produced to assist with case management and surgical planning. We used both stereolithography and polyjet techniques to produce white rigid and flexible color models, respectively. The models were discussed both at the joint multidisciplinary meeting and between surgeon and cardiologist. From the blood pool model the clinicians were able to determine that the position of the coronary arteries meant an arterial switch operation was unlikely to be feasible. The soft myocardium model allowed the clinicians to assess the VSD anatomy and relationship with the aorta. The models, therefore, were of benefit in the development of the surgical plan. It was felt that the clinical situation was stable enough that an immediate intervention was not required, but the timing of any intervention would be dictated by decreasing oxygen saturation. Subsequently, the oxygen saturation of the patient did decrease and the decision was made to intervene. A further model was created to demonstrate the tricuspid apparatus. An arterial switch was ultimately performed without the LeCompte maneuver, the muscular VSD enlarged and baffled into the neo aortic root and the perimembranous VSD closed. At 1 month follow up SO 2 was 100%, there was no breathlessness and no echocardiogram changes.

No abstract