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Book chapterAbdi A, Jeviskov J, Hussain A, et al., 2027,
Regional Myocardial Strain Estimation with MyoTrackerChrono
, Pages: 131-142Cardiovascular diseases require precise, non-invasive diagnostic tools to assess regional myocardial function. While Speckle Tracking Echocardiography (STE) is widely used to measure myocardial strain, traditional block-matching and optical flow algorithms frequently fail due to acoustic noise and out-of-plane speckle decorrelation. This paper introduces MyoTrackerChrono, a hybrid deep learning architecture designed for robust, sparse point tracking in echocardiography. By integrating a Temporal Adapter between a spatial convolutional encoder and a tracking transformer, the model explicitly aggregates temporal context early in the feature extraction phase. This allows for stable tracking even during rapid cardiac phases or momentary signal loss. Validated on physics-based synthetic benchmarks, MyoTrackerChrono improves pixel-level tracking accuracy (Mean Absolute Error) by 33.0% over baseline models and reduces strain estimation error in mechanically complex mid-wall segments by over 64%. Furthermore, the architecture operates at an effective inference rate of 1382 FPS, confirming its feasibility for rapid post-acquisition clinical deployment.
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Book chapterUfumaka I, Alibakhshi A, Fernandes P, et al., 2027,
Multi-Expert Consensus as a Label-Free Quality Surrogate for Echocardiographic LV Segmentation
, Pages: 235-247Automated left ventricular (LV) segmentation is fundamental to echocardiographic assessment of cardiac function, yet most models report aggregate performance without accounting for variation in image quality. In clinical practice, poor acoustic windows produce ambiguous endocardial boundaries where both automated predictions and expert annotations become unreliable. We propose a label-free quality surrogate, q<inf>dice</inf>, derived from pairwise Dice disagreement across 11 independent clinical experts, requiring no explicit quality labels. Using this surrogate, we conduct a quality-stratified evaluation of three architecturally distinct models (T1, T2, and T3) on the UnityLV-MultiX dataset. T1 is a sparse keypoint model, T2 uses a dense binary mask representation, and T3 is a triple-head hybrid architecture in which predicted keypoint heatmaps guide segmentation feature attention through a differentiable spatial gate. All models are trained on a single-expert dataset and evaluated against a multi-expert consensus using Dice, HD95, MSD, and ejection fraction MAE. A leave-one-out analysis enables direct comparison of model and expert consistency against a common multi-expert reference. All three models exceed every individual expert in overall Dice. T3 achieves the highest Dice across all quality bands (0.937, 0.952, and 0.960 at Q<inf>low</inf>, Q<inf>mid</inf>, and Q<inf>high</inf> respectively; 0.949 overall). It shows the lowest EF MAE overall (5.24%), representing a 38% reduction relative to the expert mean (8.46%). T3’s keypoint and segmentation heads agree far more closely with each other than any cross-model pair (ρ=0.856), yet residual disagreement between the two heads concentrates on low-quality frames, providing a built-in, single-inference reliability flag without any external reference.
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Book chapterAlibakhshi A, Jevsikov J, Ufumaka I, et al., 2027,
Phase-Guided Quality Regression in Apical Echocardiography via CNN-LSTM: A Systematic Backbone Benchmarking Study
, Pages: 17-30Apical view acquisition errors in echocardiography can lead to inaccurate estimation of clinically important measurements, including ventricular volume, ejection fraction, and strain. In this work, we propose a phase-centred CNN-LSTM framework for automated regression of apical image quality in echocardiographic studies, investigating which backbone architecture can most effectively predict a continuous reduction in left ventricular long-axis length without relying on explicit mask-based measurements. A patient-specific reference standard was generated by first identifying end-diastole using a phase detection model and then measuring LV long-axis length. For each patient, the scan with the maximum observed LV length served as the patient-specific reference, and deviations across other scans were quantified using a heuristic formulation based on relative length reduction. Using this systematic labelling strategy, eight CNN-LSTM backbone architectures were trained and compared on 1,799 echocardiographic studies from 100 patients, comprising apical four-chamber and apical two-chamber views, with the goal of directly regressing the degree of length reduction from raw image sequences alone. Across backbone comparisons, convolution-based models showed the strongest overall performance, with EfficientNetV2 achieving the lowest regression error for apical four-chamber views and ConvNeXt-Tiny and ResNet50-level models showing competitive performance in apical two-chamber views. To assess clinical relevance, two expert-annotated evaluation datasets, each labelled by 10 experts, were used for ranking-based comparison against expert consensus. The proposed AI approach demonstrated agreement with expert consensus at a level comparable to several human experts and showed meaningful ability to identify scans associated with overestimation and underestimation of key echocardiographic measurements. These findings support the potential of backbone-driven regression of apical view qua
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Journal articleAlibakhshi A, Fernandes P, Serej ND, et al., 2026,
From Relative Annotation to Pairwise Learning for Assessing Echocardiographic Rotational Alignment.
, Ultrasound Med BiolOBJECTIVE: To evaluate whether preserving relative expert-derived structure during model training improves the automated assessment of rotational misalignment in apical four-chamber echocardiographic images. METHODS: A multi-expert dataset of apical four-chamber images was annotated using multiple-image ranking to derive consensus rotational orderings along a clockwise-to-anti-clockwise continuum. Conventional pointwise regression models were compared with shared-weight pairwise models that received two images and predicted the signed difference between their consensus rotational scores. Performance was evaluated across three independent expert-ranked test sets using pairwise agreement and Spearman correlation. Robustness was further assessed using leave-one-expert-out and cycle-consistency analyses, with saliency-based visualization used to examine the image regions influencing predictions. RESULTS: Pairwise learning increased the mean pairwise agreement from 74.86% to 84.29% and the mean Spearman correlation from 67.74% to 85.43% compared with pointwise regression. The best pairwise model achieved a pairwise agreement of up to 87.81% and a Spearman correlation of up to 91.23%. The performance remained stable when individual annotators were excluded, and a cycle-consistency analysis demonstrated few cyclic preferences on independent test data. Visual explanation maps indicated model attention to clinically relevant cardiac anatomy. CONCLUSION: Training directly on relative expert-derived structure improved agreement with multi-expert consensus compared with conventional pointwise regression. Pairwise learning therefore provides a robust framework for assessing qualitative, continuous echocardiographic image-quality attributes such as rotational alignment.
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Journal articleEzad SM, Ryan M, Khan SQ, et al., 2026,
Impact of Left Ventricular Unloading on Hemodynamics and Stunning in Complex PCI: A CHIP-BCIS3 Substudy.
, J Am Coll Cardiol, Vol: 88, Pages: 1454-1466BACKGROUND: Elective left ventricular (LV) unloading during high-risk percutaneous coronary intervention (PCI) is hypothesized to mitigate hemodynamic instability and myocardial stunning, but has not been evaluated in a randomized trial. OBJECTIVES: This prespecified substudy of the CHIP-BCIS3 (Controlled Trial of High-risk Coronary Intervention With Percutaneous Left Ventricular Unloading) trial evaluated whether elective LV unloading with a microaxial flow pump (mAFP) reduces hemodynamic instability and postprocedural stunning. METHODS: Patients with severe LV systolic dysfunction undergoing complex PCI were randomized to elective LV unloading with an mAFP or standard care. Invasive hemodynamics were assessed using pulmonary artery catheterization at baseline and post-PCI. The coprimary outcomes were systolic blood pressure reduction, loss of pulse pressure (LOPP), and requirement for inotropes. Secondary outcomes included changes in cardiac index, LV filling pressure, and frequency of peri-procedural myocardial injury. RESULTS: Of 125 eligible patients, 97 were enrolled (50 mAFP; 47 standard care). Baseline cardiac index was 2.10 ± 0.55 L/min/m2. The incidence of systolic blood pressure reduction was similar between groups (relative risk [RR]: 0.86; 95% CI: 0.58-1.29), whereas inotrope use was lower with mAFP (RR: 0.57; 95% CI: 0.34-0.97). LOPP was more frequent with mAFP (RR: 7.83; 95% CI: 2.53-24.24) and was associated with peri-procedural myocardial injury (OR: 3.00; 95% CI: 1.00-9.03). Changes in cardiac index (-0.25 vs -0.24 L/min/m2; P = 0.20) and pulmonary capillary wedge pressure (2 vs 3 mm Hg; P = 0.79) were similar between groups. CONCLUSIONS: In patients undergoing complex PCI, elective LV unloading with mAFP reduced inotrope requirements but increased LOPP and did not prevent myocardial stunning. (Controlled Trial of High-risk Coronary Intervention With Percutaneous Left Ventricular Unloading [CHIP-BCIS3]; NCT05003817).
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Journal articleGupta A, Collier D, Steckelmacher J, et al., 2026,
Safety, Acceptability and Efficacy of Noninvasive Transcutaneous-Autonomic Neuromodulation in Uncontrolled Hypertension.
, HypertensionBACKGROUND: Despite antihypertensive medications, ≈40% of patients with hypertension fail to achieve recommended blood pressure (BP) targets. Alternative device-based strategies are often expensive or invasive. We evaluated the safety, acceptability, and potential efficacy of a noninvasive transcutaneous autonomic neuromodulation (tAN) device. METHODS: SCRATCH-HTN (Sham Controlled Randomized Trial Evaluating the Safety, Acceptability and Efficacy of Autonomic Neuromodulation using Transcutaneous Vagal Sensory Stimulation in Uncontrolled Hypertensive Patients) was a double-blind, sham-controlled, phase 2a trial enrolling patients with uncontrolled hypertension (mean daytime systolic BP [SBP] ≥135 mm Hg and diastolic BP ≥85 mm Hg) on 1 or more medications. Participants self-administered active tAN or sham treatment for 30 minutes daily for 14 days, then 10 weekly sessions. Primary end points were safety and acceptability. The primary efficacy end point was change in daytime ambulatory SBP from baseline to 3 months. Secondary end points included BP, heart rate, and quality of life at 1 and 3 months. RESULTS: Sixty-three patients (mean age 47.2 years, 71.4% male, mean daytime BP 150/95 mm Hg) were randomized 2:1 to tAN or sham. tAN did not differ significantly from sham in daytime ambulatory SBP at 3 months (between-group difference, 2.35 mm Hg [95% CI, -4.37 to 9.07]; P=0.49) or 1 month (-1.01 mm Hg [-6.87 to 4.85]; P=0.73). Pre-specified adjusted analysis identified a significant interaction between treatment and baseline SBP (P interaction 0.003): participants with baseline SBP >160 mm Hg showed a greater response to tAN. No significant differences were observed for other secondary end points. tAN was safe and acceptable. CONCLUSIONS: tAN is safe and well-tolerated in patients with hypertension. No significant BP-lowering effect was demonstrated, although a potential benefit in subgroups or a modest effect in a
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Journal articleShun-Shin M, Whinnett Z, 2026,
Cardiac resynchronisation therapy: 30 years of progress.
, Lancet, Vol: 408, Pages: 1150-1151 -
Journal articleKim JU, Kaza N, Zuhair M, et al., 2026,
Atrial Dyssynchrony and Bachmann Bundle Pacing: A Review.
, JAMA Cardiol, Vol: 11, Pages: 880-887IMPORTANCE: Cardiac dyssynchrony disrupts coordinated chamber activation and is associated with impaired cardiac function and adverse clinical outcomes. While ventricular dyssynchrony has been targeted through biventricular and conduction system pacing, atrial dyssynchrony remains underrecognized and largely untreated. OBSERVATIONS: Interatrial dyssynchrony commonly arises from delayed or impaired conduction through Bachmann bundle or from nonphysiological atrial pacing. It is associated with impaired ventricular filling and increased atrial arrhythmia risk. Importantly, conventional atrial pacing strategies may exacerbate rather than correct abnormal atrial activation. Bachmann bundle pacing represents a potential strategy to restore physiological atrial activation by engaging the dominant interatrial conduction pathway. Emerging data suggest that this approach may improve atrial synchrony, optimize atrioventricular timing, and reduce arrhythmia burden. CONCLUSIONS AND RELEVANCE: In this review, we summarize the mechanisms and clinical consequences of interatrial dyssynchrony and evaluate the role of Bachmann bundle pacing as a novel target for atrial resynchronization and a potential next step in physiological pacing. Further studies are required to define optimal implantation strategies and determine Bachmann bundle pacing's clinical impact.
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Journal articleRajendra S, Salmasi Y, Raj B, et al., 2026,
Haemodynamics from Induction to Cardiopulmonary Bypass Improve Prediction of Right Ventricular Failure Following Left Ventricular Assist Device.
, Interdiscip Cardiovasc Thorac Surg, Vol: 41OBJECTIVES: Right ventricular failure (RVF) remains a frequent complication following left ventricular assist device (LVAD) implantation. Conventional risk scores rely on preoperative data acquired under stable conditions, which may overlook early signs of RV decompensation that emerge under perioperative stress. This study evaluates whether perioperative haemodynamic markers prior to cardiopulmonary bypass (CPB) improve RVF prediction compared to preoperative assessment obtained by right heart catheterization (RHC), echocardiographic parameters, and scoring systems such as the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) RHF score. METHODS: We conducted a retrospective single-centre study of 203 LVAD patients (2013-2023). The primary outcome was RVF. Preoperative data included clinical variables, echocardiography, and RHC. Perioperative data included vasoactive-inotropic score (VIS), pulmonary artery (PA) catheter, and arterial-line monitoring between induction and start of CPB. Two multivariable models were developed using least absolute shrinkage-and-selection operator (LASSO) logistic regression: (1) Preoperative model; (2) Pre-CPB model. Model performance was assessed using area under the curve (AUC) and compared against EUROMACS-RHF using DeLong tests. RESULTS: Thirty-six patients (17.7%) developed RVF. No preoperative RHC-derived parameter independently predicted RVF. The Preoperative model achieved moderate discrimination (AUC: 0.747). Incorporating intraoperative mean arterial pressure (MAP), pulmonary artery pulsatility index (PAPi), and maximum VIS yielded a Pre-CPB model with strong discrimination (AUC: 0.834). The Pre-CPB model significantly outperformed both EUROMACS-RHF (P = 0.0299) and the Preoperative model (P = 0.049), with no significant difference between our Preoperative model and EUROMACS-RHF (P = 0.222). CONCLUSIONS: Perioperative markers prior to CPB significantly outp
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Journal articleBlackman J, Quon S, Francis DP, et al., 2026,
Association Between Interventional Cardiologist Practice Characteristics, Coronary Artery Bypass Grafting Use, and Clinical Outcomes.
, Eur J Cardiothorac Surg, Vol: 68OBJECTIVES: Quantify inter-operator variation in referred coronary artery bypass grafting (CABG) following angiography and evaluate associations with practice patterns and long-term outcomes. METHODS: Observational study using administrative health data in British Columbia, Canada (2010-2024). Interventional cardiologist-level CABG Rate was defined as the proportion of referred CABGs to total angiograms performed. Variation across Interventionalists was correlated with other practice characteristics. Among patients undergoing angiography followed by revascularization, associations between operator CABG Rate and all-cause mortality, major adverse cardiovascular events (MACEs), and repeat revascularization were evaluated using hierarchical Cox regression. RESULTS: Among 252 408 angiograms by 40 Interventionalists, CABG Rate varied 13-fold (2.03%-26.4%) and was not explained by hospital-level factors alone (intraclass correlation coefficient [ICC]: 0.358; 95% confidence interval [CI], 0.054-0.621). Higher CABG Rates were associated with lower percutaneous coronary intervention (PCI) utilization (R = -0.60; P < .001), lower PCI extensiveness (R = -0.52; P < .001), and lower procedural volume (R = -0.36; P = .022). In 73,603 first-time revascularized patients, CABG Rate was associated with reduced repeat revascularization (hazard ratio [HR] = 0.075; P < .001), without differences in mortality or MACE. CONCLUSIONS: Referred CABG varies markedly between Interventionalists and reflects operator practice style. Higher CABG utilization is associated with more durable revascularization without impact on survival or MACE. Broader implementation of multidisciplinary Heart Teams may improve consistency of care.
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Journal articleKhan S, Sajjad U, Fawaz S, et al., 2026,
Randomized, Placebo-Controlled Trial of Chronic Total Occlusion Percutaneous Coronary Intervention in Stable Angina: The ORBITA-CTO Trial.
, J Am Coll Cardiol, Vol: 88, Pages: 4-18BACKGROUND: Percutaneous coronary intervention for coronary chronic total occlusion (CTO PCI) is offered for symptom and quality of life improvement, despite the absence of blinded randomized evidence. OBJECTIVES: The aim of this study was to assess the efficacy of CTO PCI in the first randomized, placebo-controlled trial of CTO PCI. METHODS: ORBITA-CTO is a multicenter, randomized, blinded trial comparing CTO PCI with a placebo procedure. Patients had angina attributable to a single-vessel CTO, without bystander coronary disease. Angina symptoms were recorded daily using the ORBITA app. After dual-injection coronary angiography, patients were randomized to either CTO PCI or placebo. Blinding was maintained using auditory isolation and deep conscious sedation. Antianginal medications were stopped at randomization and reintroduced on a patient-initiated protocol. At the 6-month follow-up, assessments were repeated. The primary efficacy outcome was the angina symptom score, an ordinal scale combining the daily symptom burden assessed by the ORBITA app, antianginal use, and over-ride events. Secondary outcomes were symptom and quality of life questionnaires and blinding fidelity. RESULTS: Between October 19, 2021 and October 21, 2025, 50 patients were randomly assigned to CTO PCI (n = 25) or placebo (n = 25). One patient randomized to PCI was withdrawn during the procedure because of a complication. All 50 patients were included in the primary analysis. Compared with placebo, CTO PCI resulted in an immediate and sustained improvement in the angina symptom score (OR: 4.38; 95% credible interval [CrI]: 1.57-12.69; probability of benefit [Pr{Benefit}] = 0.996), arising from a clear reduction in the number of episodes of angina (OR: 4.38; 95% CrI: 1.55-11.78; Pr[Benefit] = 0.997). This resulted in an additional 30.6 days free of angina (95% CrI: 11.1-50.7; Pr[Benefit] >0.999). Improvements were also observed with the Seattle Angina Questionnaire in angina frequency (+10
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Journal articleChiew K, Foley MJ, Chotai S, et al., 2026,
Focal and Diffuse Coronary Artery Disease Patterns and Placebo-Controlled Angina Relief With Percutaneous Coronary Intervention: ORBITA-2.
, J Am Coll Cardiol, Vol: 88, Pages: 42-58BACKGROUND: Unblinded studies have demonstrated superior procedural and clinical outcomes of percutaneous coronary intervention (PCI) in focal compared with diffuse coronary artery disease. However, data from the first placebo-controlled study did not demonstrate a differential impact of disease pattern on symptom endpoints. OBJECTIVES: The study sought to test the ability of pattern of coronary artery disease to predict the placebo-controlled efficacy of PCI. METHOD: In the ORBITA-2 (Objective Randomised Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina-2) randomized placebo-controlled trial of angioplasty for stable angina, patients underwent prerandomization nonhyperemic pressure wire pullback assessments. Seven blinded interventional cardiologists independently reviewed each pullback trace to categorize disease patterns as focal, diffuse, or mixed. These were assigned numerical values of 1, 0, and 0.5, respectively. Overall disease pattern score was determined by the mean. A score >0.5 was considered focal and ≤0.5 was considered diffuse. Bayesian proportional odds modeling was used. RESULTS: A total of 245 patients with 300 target vessel pullbacks were analyzed. With adjustment for prerandomization nonhyperemic pressure ratio, PCI in focal compared with diffuse disease resulted in greater improvement in angina symptom score (OR: 1.80; 95% credible interval [CrI]: 1.48-2.18; Pr[Benefit] > 99.9%) and daily episodes of angina (OR: 1.55; 95% CrI: 1.26-1.89; Pr[Benefit] > 99.9%). Focal disease also predicted greater placebo-controlled benefit in exercise treadmill time (Pr[Interaction] > 99.9%), Canadian Cardiovascular Society class (Pr[Interaction] = 99.0%), EuroQol Group 5-Dimensions 5-Level questionnaire (Pr[Interaction] = 95.1%), and Seattle Angina Questionnaire angina frequency (Pr[Interaction] = 99.5%). There was weaker evidence of interaction between disease pattern and the placebo-controlled impact of PCI on im
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Journal articleFearon WF, Jeremias A, Witberg G, et al., 2026,
Angiography-Derived Fractional Flow Reserve to Guide PCI.
, N Engl J Med, Vol: 395, Pages: 9-19BACKGROUND: Assessing intermediate coronary lesions with an intracoronary pressure wire improves clinical outcomes in patients undergoing cardiac catheterization and percutaneous coronary intervention (PCI). However, clinical use of pressure-wire-based physiological assessment remains low. Measurement of fractional flow reserve (FFR) derived from coronary angiographic images alone correlates well with pressure-wire-based FFR measurements and may simplify procedures, but its effect on clinical outcomes is unknown. METHODS: In this international noninferiority trial, we randomly assigned patients undergoing coronary angiography who were found to have at least one intermediate coronary stenosis to physiological assessment with measurements derived from angiographic images (FFRangio) or with pressure-wire-based measurements. The primary end point was a composite of death, myocardial infarction, or unplanned, clinically indicated coronary revascularization at 1 year. The noninferiority margin was 3.5 percentage points. RESULTS: A total of 1930 patients were randomly assigned to physiological assessment with FFRangio (FFRangio group; 965 patients) or a pressure-wire-based approach (pressure-wire group; 965 patients). The mean age of the patients was 68.4 years, and 25.0% of the patients were women. At 1 year, a primary end-point event had occurred in 64 patients (Kaplan-Meier estimate, 6.9%) in the FFRangio group and 65 patients (Kaplan-Meier estimate, 7.1%) in the pressure-wire group (hazard ratio, 0.98; 95% confidence interval, 0.70 to 1.39; difference, -0.2 percentage points; upper boundary of the one-sided 97.5% confidence interval, 2.1 percentage points; P<0.001 for noninferiority). There were no apparent differences between the groups with respect to the incidence of bleeding, acute kidney injury, or procedure-related adverse events. CONCLUSIONS: Among patients with intermediate coronary-artery lesions undergoing physiological assessment in the cardiac catheteriz
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Journal articleNaderi Z, Al-Lamee R, 2026,
Coronary artery disease: stable angina
, Medicine United Kingdom, Vol: 54, Pages: 475-482, ISSN: 1357-3039A global public health issue, coronary artery disease (CAD) is recognized as the leading cause of morbidity and mortality worldwide. Stable angina, a symptom of CAD, is defined as chest pain typically triggered by exertion or emotional distress and relieved by rest. Effective history-taking, assessing the nature and frequency of symptoms, a good physical examination and identifying key risk factors is vital in the initial care of patients with stable angina, allowing clinicians to opt for the most suitable test to investigate further. Over the last three decades, research has explored the most effective treatment modalities for the management of stable angina, in the form of percutaneous coronary intervention, coronary artery bypass graft surgery and medical therapy. Furthermore, understanding the definition of stable angina, its pathophysiology and patient symptomatology is key to developing trials to address some of the remaining unanswered questions. This chapter outlines some of the most important randomized controlled trials that have played a key role in developing our understanding of the complex aetiology of symptom management, most effective treatments and long-term outcomes of patients with stable angina.
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Journal articleMorrow A, Young R, Abraham GR, et al., 2026,
Exercise treadmill testing for efficacy evaluation in randomized, controlled trials.
, Am Heart J, Vol: 297Exercise treadmill testing measures functional capacity and inducible myocardial ischemia and has historically served as an endpoint in phase 2 trials. The Precision Medicine with Zibotentan in Microvascular Angina trial evaluated the selective endothelin-A receptor antagonist zibotentan as a potential disease-modifying therapy for microvascular angina. The trial had a randomized, double-blind, cross-over design and the primary outcome was exercise duration. Compared with placebo, zibotentan at a dose of 10-mg daily for 12-weeks did not improve exercise duration or angina symptoms. In this prespecified analysis, exercise duration was compared across four sequential study visits and the factors associated with within-trial changes were evaluated. Exercise test duration increased progressively in all participants during sequential trial phases, independent of treatment with either zibotentan or placebo. This improvement in exercise duration was associated with female sex (interaction p-value = .0213; effect estimate [95% confidence interval]) 34.95 [13.99, 55.78] seconds, P = .002). In conclusion, the exercise test has limitations as an objective endpoint of efficacy in randomized trials. PRIZE; https://clinicaltrials.gov/study/NCT04097314 Clinicaltrials.gov Registration: NCT04097314.
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Journal articleAhmed-Jushuf F, Foley MJ, Chotai S, et al., 2026,
Determining the Physiological Threshold for Angina (ORBITA-FIRE): A Double-Blind, Randomized, Placebo-Controlled Study.
, Circulation, Vol: 153, Pages: 1795-1812BACKGROUND: In stable coronary artery disease, the primary goal of percutaneous coronary intervention (PCI) is symptom relief. Fractional flow reserve (FFR) and nonhyperemic pressure ratios such as resting full-cycle ratio (RFR) are used to guide revascularization. Although these indices correlate with myocardial ischemia, they have never been validated against the onset of angina. The physiological thresholds for angina, FFRangina and RFRangina, angina (FFRangina at rest and during exercise remain undefined. METHODS: ORBITA-FIRE (Finding the Invasive Threshold for Symptom Relief in Exertional Angina) was a multicenter, double-blind, randomized, placebo-controlled study in patients with stable angina and single-vessel coronary artery disease. After imaging-guided PCI, an in-stent balloon was incrementally inflated until angina occurred at rest. This angina threshold was verified against placebo inflation, and corresponding FFRangina and RFRangina values were recorded at symptom onset. The protocol was repeated during low- and high-intensity exercise to assess changes in angina thresholds with increasing cardiac workload. RESULTS: Sixty-five patients were enrolled (mean age, 63.9±8.7 years; 74% male; 69% hypertensive; 23% diabetic; 91% with Canadian Cardiovascular Society class II-III angina). Median pre-PCI FFR was 0.59 (interquartile range [IQR], 0.46-0.70) and RFR was 0.61 (IQR, 0.40-0.82). Median FFRangina at rest was 0.29 (IQR, 0.23-0.35), increasing to 0.38 (IQR, 0.30-0.48) during low-intensity exercise and 0.45 (IQR, 0.36-0.55) during high-intensity exercise. RFRangina similarly increased from 0.22 (IQR, 0.16-0.30) at rest to 0.26 (IQR, 0.18-0.36) and 0.32 (IQR, 0.23-0.46) during low- and high-intensity exercise. All thresholds were significantly lower than clinical diagnostic cut points (P<0.001). Lower FFRangina and RFRangina thresholds were associated with greater symptom reproducibility across rest, low- and high-intensity exercise conditions (FF
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Journal articleLuo Y, Sesia D, Wang F, et al., 2026,
Explicit differentiable slicing and global deformation for cardiac mesh reconstruction.
, Med Image Anal, Vol: 111Three-dimensional (3D) mesh reconstruction of the cardiac anatomy from medical images is useful for shape and motion measurements and biophysics simulations. However, 3D medical images are often acquired as 2D slices that are sparsely sampled (e.g., large slice spacing) and noisy, and 3D mesh reconstruction on such data is a challenging task. Traditional voxel-based approaches utilize non-differentiable pre- and post-processing that compromises fidelity to images, while mesh-level deep learning approaches require large 3D mesh annotations that are difficult to obtain. Differentiable cross-domain supervision from 2D images to 3D meshes is therefore crucial for enabling end-to-end optimization in medical imaging. While there have been attempts to approximate the voxelization and slicing of meshes that are being optimized, there has not yet been a method for directly using 2D slices to supervise 3D mesh reconstruction in a differentiable manner. Here, we propose a novel explicit differentiable voxelization and slicing (DVS) algorithm allowing gradient backpropagation to a 3D mesh from its slices, which facilitates refined mesh optimization directly supervised by the losses defined on 2D images. Further, we propose an innovative framework for extracting patient-specific left ventricle (LV) meshes from medical images by coupling DVS with a graph harmonic deformation (GHD) mesh morphing descriptor of cardiac shape that naturally preserves mesh quality and smoothness during optimization. The proposed framework achieves state-of-the-art performance in cardiac mesh reconstruction tasks from densely sampled (CT) as well as sparsely sampled (MRI stack with few slices) images, outperforming alternatives, including Marching Cubes, statistical shape models, algorithms with vertex-based mesh morphing algorithms and alternative methods for image-supervision of mesh reconstruction. Experimental results demonstrate that our method achieves an overall Dice score of 90% during a sparse
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Journal articleCheng K, Witherow F, Byrne J, et al., 2026,
Coronary sinus reducer implantation for refractory angina: a national audit of UK practice.
, HeartBACKGROUND: Coronary sinus reducer (CSR) implantation is the only guideline-recommended percutaneous treatment for patients with refractory angina. Data from its real-world large-scale adoption are scarce. METHODS: This was a national audit of CSR implanting centres in the UK between November 2014 and 2024. Centres provided data on all patients undergoing clinical CSR implantation through a structured collection template. Data collected included demographics, medical history, medications, angina status, ischaemia testing, procedural characteristics and periprocedural complications. Prespecified endpoints were appropriate patient selection, procedural success and safety, and efficacy of CSR implantation. RESULTS: 19 centres were included capturing 491 patients. Most were male (79%) with high rates of previous myocardial infarction (75%), percutaneous coronary intervention (78%) and coronary artery bypass grafting (69%). Diabetes mellitus (53%), hypertension (76%) and hypercholesterolaemia (78%) were prevalent. 74% had a preserved left ventricular ejection fraction (LVEF≥50%). Patients were severely symptomatic with 84% suffering from Canadian Cardiovascular Society (CCS) class ≥3 angina despite multiple antianginal medications (≥2 drugs 94%; ≥3 drugs 74%). Baseline ischaemia testing was common (79%). Successful CSR implantation was achieved in 95% of cases. 46 periprocedural adverse events (AEs) in 41 patients occurred (9.2%) most commonly due to access complications. Rates of major adverse cardiovascular events and severe AEs were low (<1%). 98% of patients stayed ≤1 night postprocedurally. Significant reductions in CCS class were observed at 6-month follow-up: 75% experienced ≥1 CCS class and 36% ≥2 CCS class angina reduction. Improved angina status was also observed after stratification by age, sex and diabetes mellitus. CONCLUSIONS: This national audit of real-world UK practice confirms CSR implantation is being performed app
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Journal articleTaylor DJ, Yones E, Newman T, et al., 2026,
Coronary Microvascular Resistance as a Predictor of the Placebo-Controlled Response to Percutaneous Coronary Intervention: Microvascular-Stratified Analysis of ORBITA.
, JACC Cardiovasc Interv, Vol: 19, Pages: 1259-1270BACKGROUND: The first placebo-controlled trial of percutaneous coronary intervention (PCI), ORBITA (Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina; NCT02062593), showed minimal symptom benefit with PCI. No placebo-controlled data describing the relationship between microvascular resistance (MVR) and PCI exist. The authors hypothesized that patients with low MVR would derive the greatest benefit from PCI. OBJECTIVES: The aims of this study were to compute MVR in patients recruited for ORBITA and to evaluate interactions with prespecified endpoints. METHODS: Hyperemic MVR was calculated using computational fluid dynamics (CFD) and compared against placebo-controlled changes in treadmill exercise time, patient-reported symptoms, physician-assessed symptoms, and dobutamine stress echocardiography scores at 6-week follow-up. RESULTS: MVRCFD was computed for 131 patients (66 undergoing PCI and 65 placebo). Median MVRCFD was 1.38 mm Hg · min/mL (Q1-Q3: 0.89-2.09 mm Hg · min/mL). Baseline exercise time correlated with MVRCFD (ordinal correlation coefficient = 0.20; 95% credible interval [CrI]: 0.18-0.22). For patients with low (20th centile) MVRCFD, PCI increased exercise time by 48 seconds vs placebo (95% CrI: 6-92 seconds; Pr = 98.5%). Exercise time did not improve for patients with high (80th centile) MVRCFD (16 seconds; 95% CrI: -29 to 61 seconds; probability of significant difference [Pr] = 75.2%), but evidence for an interaction was modest (Printeraction = 83.1%). Low MVRCFD was also associated with a placebo-controlled benefit of PCI for likelihood of complete freedom from angina (Pr = 98.8%) and improvements in angina frequency (Pr = 97.8%) and stress echocardiography scores (Pr = 99.9%). CONCLUSIONS: The placebo-controlled benefit of PCI was greater in patients with lower MVRCFD, but interactions with symptom-based endpoints were modest. For patients with severe single-vessel disease taking opti
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Journal articlePreston AJ, Blackman J, Krahn AD, et al., 2026,
Pace and Ablate or Pace Then Ablate: Defining the Risk of Concomitant AV Node Ablation and Pacemaker Implantation Using a Probability Based Approach.
, Circ Arrhythm Electrophysiol, Vol: 19 -
Journal articleKoo CYC, Li S, Al-Lamee R, et al., 2026,
Angiography-Derived Fractional Flow Reserve During Percutaneous Coronary Intervention.
, Circ Cardiovasc Interv, Vol: 19BACKGROUND: Angiography-derived fractional flow reserve (Angio-FFR) is an emerging tool for guiding percutaneous coronary intervention (PCI). Its uptake and outcomes compared with pressure wire (PW)-based assessment in the United States are unknown. METHODS: We conducted a cohort study using US Medicare beneficiary data from January 1, 2019 to December 31, 2024. Propensity score matching (1:3) of Angio-FFR to PW was performed in patients who underwent PCI during the same procedure, and separately among those who did not undergo PCI during the same procedure. The primary outcome was the cumulative incidence of major adverse cardiovascular events through 2 years, including all-cause death, myocardial infarction, and repeat revascularization. Secondary outcomes included individual major adverse cardiovascular event components, 30-day acute kidney injury, and 30-day major bleeding. Falsification end points (hospitalization for pneumonia and hip fracture) were used to assess unmeasured confounding. RESULTS: Of 466 535 angiograms that included intraprocedural physiological assessment, 1.00% (N=4672) used Angio-FFR. Annual use increased from 0.47% in 2019 to 3.85% in 2024. Among patients with PCI, 1591 Angio-FFR and 4773 PW-matched patients with PCI had similar major adverse cardiovascular event rates through 2 years (24.8% versus 23.5%; hazard ratio, 1.01 [95% CI, 0.85-1.20]). Secondary outcomes and falsification end points were not significantly different. In non-PCI patients, 2532 Angio-FFR and 7596 PW-matched patients also had similar major adverse cardiovascular events through 2 years (24.1% versus 23.9%; hazard ratio, 0.97 [95% CI, 0.84-1.11]). CONCLUSIONS: Angio-FFR usage in the United States is modest but increasing. Angio-FFR guidance during angiography versus PW was associated with comparable outcomes through 2 years.
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Journal articleNaidoo P, Fernandes P, Dadashi Serej N, et al., 2026,
Robust fine-grained echocardiographic view classification with supervised contrastive learning.
, Med Image Anal, Vol: 110Accurate classification of echocardiographic views is fundamental for automated cardiac analysis. However, clinical practice relies on a large, heterogeneous set of fine-grained acquisitions that introduce substantial inter-observer variability. Existing studies have primarily focused on limited view sets, often collapsing specialised views into broad categories, which limits their clinical relevance. We address this limitation by introducing TTE47, the first publicly available benchmark comprising 47 clinically meaningful views annotated independently by three experts. This dataset enables the rigorous quantification of inter-observer agreement and establishes a foundation for reproducible, clinically relevant evaluation. To tackle the dual challenges of subtle inter-class distinctions and structured label variability, we propose a novel supervised contrastive learning framework incorporating a tailored loss function. Our method outperforms cross-entropy and standard supervised contrastive baselines, achieving leading performance among evaluated methods on TTE47 and surpassing prior work on TMED-2 without dataset-specific pretraining, using a model pretrained on TTE47. Beyond accuracy, we introduce clustering-based metrics, Detection Rate and Label Recovery Precision, that measure semantic coherence and the model's ability to resist annotation variability. Results show that the learned feature space aligns more strongly with underlying anatomical structure than with any single annotator's style, enabling resilience to label shifts and maintaining robustness comparable to human-level disagreement. By integrating multi-expert evaluation, robust representation learning, and interpretable feature-space analysis, this work establishes a scalable and clinically relevant framework for fine-grained echo view classification. Our findings highlight the potential of contrastive pretraining to standardise interpretation, mitigate subjectivity, and enhance the reliability of AI
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Journal articleZiaeian B, Shaw LJ, Sutton NR, et al., 2026,
Strategy to Reduce >350 000 Yearly Deaths From Atherosclerotic Coronary Artery Disease by 2050 in the United States.
, Circ Popul Health Outcomes, Vol: 19 -
Journal articleStevens C, Smith J, Brandts J, et al., 2026,
Optimising lipid-lowering therapy for acute coronary syndrome using a decision support system: insights from a cluster randomised trial
, European Heart Journal: Digital Health, Vol: 7, ISSN: 2634-3916AIMS: Lipid-lowering therapy (LLT) after acute coronary syndrome (ACS) typically follows stepwise intensification, delaying use of combination therapies and LDL-C goal attainment. We assessed whether access to a Decision Support System (DSS) altered the intensity of LLT prescribing vs standard-of-care (SoC).METHODS: Pragmatic, multinational, parallel 1:1 cluster-randomised controlled trial of ACS patients comparingmandatory access to a DSS (providing estimates of cardiovascular events and benefits from different LLT scenarios) to SoC. The primary endpoint was the proportion receiving intensified monotherapy or initiated/escalated combination LLT by week 16 compared to pre-admission LLT; secondary endpoints included individual components of the primary endpoint, proportions at goal (LDL-C<1.4mmol/L), and timing of LLT escalations.RESULTS: 42 sites from UK, Italy and Spain were randomised, enrolling 1139 participants, 79% male, median age 62 years (IQR: 55, 69), 84% without prior CVD, 69% LLT-naïve at admission, median admission LDL-C 3.0 mmol/L (IQR: 2.46, 3.75). The primary endpoint was met in 71.7% (DSS) vs 65.7% (SoC), risk ratio (RR) 1.11 (95%CI:0.92-1.33, p=0.29). Intensification of monotherapy occurred in 9.0% vs 13.1% (RR:0.68, 95%CI:0.46-1.00), combination LLT in 61.6% vs 50.6% (RR:1.35, 95%CI:0.93-1.98). LDL-C goal achievement was 54.8% vs 50.3% (RR 1.06, 95%CI: 0.88-1.28), with LLT escalation before discharge in 64.8% vs 60.7%.CONCLUSIONS: Access to a DSS, in hospitals managing ACS, did not improve LLT intensification within 16 weeks or LDL-C goal attainment, but revealed a favourable trend towards earlier combination LLT use, which merits larger, longer studies in other settings.
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Journal articleToth GG, Amabile N, Barbato E, et al., 2026,
Day-case percutaneous coronary procedures. A clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology (ESC) and the Association of Cardiovascular Nursing & Allied Professions (ACNAP) of the ESC.
, EuroIntervention, Vol: 22, Pages: 224-231Percutaneous coronary procedures performed in a day-case setting are intended to facilitate an optimised resource allocation and increase patient satisfaction without compromising procedural and long-term safety or efficacy. While an increasing number of centres have implemented a day-case approach, patient pathways and procedural aspects still lack standardisation, potentially leading to a large heterogeneity in practices. However, several centres and healthcare systems are still reluctant to adopt day-case diagnostic or therapeutic coronary procedures because of safety concerns, penalising reimbursement policies, or simple inertia. This clinical consensus statement summarises experience-based know-how and research-derived data on day-case coronary procedures with the objective of providing standardised practical guidance on patient selection, procedural considerations, and postprocedural management to facilitate wide-scale adoption of a day-case coronary programme. The document also provides clear advice on when such procedures must be converted into regular admissions to maximise patient safety.
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