Cardiovascular Imaging

Cardiac magnetic resonance-tissue tracking for the early prediction of adverse left ventricular remodeling after ST-segment elevation myocardial infarction Abstract Cardiac magnetic resonance-tissue tracking (CMR-TT)-derived myocardial strain after ST-elevation myocardial infarction (STEMI) is related to adverse cardiac events. We aimed to investigate the feasibility of CMR-TT for the early prediction of adverse left ventricular (LV) remodeling after STEMI. We retrospectively searched our institution's STEMI registry for patients who underwent reperfusion therapy, post-reperfusion CMR within 1 week after STEMI, and follow-up CMR. CMR-TT analysis was performed using cine imaging of post-reperfusion CMR. Adverse LV remodeling was defined as an increase in end-diastolic LV volume by 20% or more on follow-up CMR (median interval between serial CMR exams, 197 days; interquartile, 174–241 days). A total of 82 patients (age, 59.2 ± 11.1 years; male:female = 73:9) were included and divided into two groups: STEMI without (n = 62) and with (n = 20) adverse LV remodeling. Patients with LV remodeling showed significantly higher peak creatine kinase-MB and troponin I levels and a larger infarct size compared with those without LV remodeling (p = 0.001, p = 0.001, and p = 0.010, respectively). Global circumferential, radial, and longitudinal strain (GLS) also differed significantly between the groups (p = 0.001, p = 0.004, and p < 0.001, respectively). Logistic regression and receiver operating characteristic curve analyses demonstrated that GLS was an independent predictor of LV remodeling [odds ratio (OR) = 1.282, 95% confidence interval (CI) = 1.060–1.55 p = 0.011] with an optimal cut-off of − 12.84 (AUC = 0.756, 95% CI = 0.636–0.887, p < 0.001). CMR-TT-derived GLS may aid the early prediction of adverse LV remodeling after reperfusion, within 1 week after STEMI.

Aortic CT angiography using the double region of interest timing bolus technique: feasibility of 80 kVp scanning in lean patients Abstract To investigate the feasibility of aortic computed tomography angiography (CTA) performed at 80 kVp in lean patients using the double region of interest timing bolus (DRTB) technique compared to 100 kVp scanning. This study was approved by the institutional ethics committee, and all patients provided written informed consent. We prospectively included 165 patients from July 2018 to February 2019. We used an 80 kVp protocol when the maximal tube current did not exceed the limit using automatic exposure control; otherwise, 100 kVp was selected. The scan parameters for aortic CTA were determined from the test scan data. Enhancement at six points of the aortoiliac arteries and noise at the bifurcation level were measured. We compared the enhancement and signal to noise ratio (SNR) using Student's t-test. The tube voltage was 80 kVp in 87 patients (53%). The enhancement of the aortoiliac arteries was significantly higher (449.3 ± 77.8 vs 378.7 ± 53.1 HU, p < 0.0001) and the SNR was similar (42.4 ± 11.1 vs 40.0 ± 10.6, p = 0.17), and the amount of contrast medium was lower (33.0 ± 2.5 vs 41.8 ± 3.3 ml, p < 0.001) in the 80 kVp group compared to the 100 kVp group. Reducing the tube current to 80 kVp could decrease the amount of contrast medium used compared to the 100 kVp protocol, while maintaining image quality, for aortic CTA using the DRTB technique.

Editor's note February 2019

Left atrial volume index and left ventricular global longitudinal strain predict new-onset atrial fibrillation in patients with transient ischemic attack Abstract This study aimed to investigate different echocardiographic parameters for predicting atrial fibrillation (AF) in patients with transient ischemic attack (TIA). Echocardiography was performed in 110 patients (median age 65.8 years, 53% males) with TIA and no history of stroke or AF. All patients underwent monitoring with ECG and 72 h Holter-monitoring, and if no AF was found, an insertable cardiac monitor (ICM) was implanted and patients were followed for a median of 2.2 years. AF was found in 14 patients: five with Holter-monitoring and nine with ICM. AF patients had significantly larger left atrial (LA) volumes indexes compared to patients without AF (26.7 vs. 33.7 ml/m2, P = 0.03 for 2D images and 26.5 vs. 33.5 ml/m2, P = 0.0008 for 3D images). Patients with AF also had depressed LA function assessed with LA emptying fraction measured with 2D echocardiography (46.3 vs. 57.3%, P = 0.005 for patients with and without AF, respectively). Patients with AF also had depressed left ventricular (LV) function compared to patients without AF. LV ejection fraction was 55 versus 61%, P = 0.04 in patients with and without AF, respectively. LV global longitudinal strain (absolute value) was 16.7 in patients with AF compared to 21.2 in patients without AF (P = 0.001). Echocardiographic measurements of LA and LV size and function can noninvasively predict AF in patients with TIA and could potentially be used to guide AF monitoring strategy.

Predictive value of exercise stress echocardiography in asymptomatic patients with severe aortic regurgitation and preserved left ventricular systolic function without LV dilatation Abstract The management of asymptomatic patients with severe aortic regurgitation (AR) and preserved left ventricular (LV) systolic function remains controversial. We evaluated the predictive value of exercise stress echocardiography (ESE) in asymptomatic severe AR with preserved LV systolic function for identifying high risk patients who might benefit from early referral for surgery. Symptom-limited treadmill ESE was performed in 67 asymptomatic patients with severe AR (effective regurgitant orifice area > 30 mm2, regurgitant volume > 60 ml) and preserved LV systolic function without LV dilatation [ejection fraction (EF) ≥ 50% and LV end-systolic diameter ≤ 50 mm]. A post-exercise EF increase of > 4% was defined as presence of contractile reserve (CR). The primary outcome was defined as the composite of symptoms development, deterioration in LV function (EF < 50% in echocardiography) and aortic valve replacement (AVR) at follow-up. Operations performed within 60 days of ESE were excluded. Twenty-eight patients were CR (+) and 39 patients were CR (−). Compared with the CR (+) group, the CR (−) group was older (52.0 ± 14.0 years vs. 43.8 ± 10.6 years, p = 0.011) and had higher Ln N-terminal natriuretic peptide (NT-proBNP) [5.2 (4.5–5.7) vs. 4.1 (3.7–5.1), p = 0.001]. The CR (−) group showed lower exercise time than the CR (+) group (576 ± 159 s vs. 671 ± 108 s, p = 0.008). Otherwise, there were no differences in demographics and imaging data between the two groups. During a follow-up duration of 46 ± 23 months, the primary outcome occurred in 17 patients (25%) including development of symptoms (n = 9), new-onset LV systolic dysfunction (n = 1) and AVR (n = 7). Fourteen of 17 were CR (−) group patients. The survival rate during follow-up was significantly lower in the CR (−) group than in the CR (+) group of asymptomatic severe AR patients (log-rank p = 0.035). The absence of CR in ESE is independently associated with deterioration of symptoms or LV systolic function in asymptomatic patients with severe AR and preserved LV systolic function. It can further risk stratify asymptomatic patients with severe AR and preserved LV systolic function and may influence the optimal timing of AVR.

Cardiovascular imaging 2018 in the International Journal of Cardiovascular Imaging

Value of 18 F-FDG PET/CT in differentiating malignancy of pulmonary artery from pulmonary thromboembolism: a cohort study and literature review Abstract To determine the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in differentiating malignancy of pulmonary artery (PA) from pulmonary thromboembolism (PTE) based on a larger number of cases by pooling our cases and those from the literature. Consecutive patients with a PA lesion who had undergone 18F-FDG PET/CT in our hospital were retrospectively reviewed. Moreover, PubMed, Embase, and Medline were searched for literature reporting individual maximum standardised uptake value (SUVmax) of the malignant PA lesion and/or PTE. 18F-FDG activity was compared between PA malignancy and PTE by pooling the data from literature and our patients. Receiver operating characteristic curve analysis was performed to determine the ability of SUVmax to differentiate PA malignancy from PTE. From our database, we identified 11 patients with pulmonary artery sarcoma (PAS), and nine cases of PTE. Fifty patients with a malignant PA lesion (40 cases of PAS and 10 cases of tumor embolism) and 22 subjects with PTE were extracted from the literature. In our cases, the SUVmax of PAS (11.1 ± 4.9, range: 5.5–19.9) was significantly higher than that of PTE (1.9 ± 0.6, range: 1.1–3.2; P < 0.001). There was no significant difference in the SUVmax between the literature data and our cases in malignant lesions or in PTE. Based on the pooled analysis of the literature data and our cases (61 cases of malignant lesions and 31 cases of PTE), the area under the curve for SUVmax to differentiate PA malignancy from PTE was 0.996 (95% CI: 0.989–1.000). At a cutoff value of 3.3, the sensitivity, specificity, and accuracy were 98.4%, 96.8%, and 97.8%, respectively. The 18F-FDG uptake value is an accurate index for determining PA malignancy.

Addition of price transparency to an education and feedback intervention reduces utilization of inpatient echocardiography by resident physicians Abstract Previous studies have demonstrated the impact of appropriate use criteria (AUC) education and feedback interventions in reducing unnecessary ordering of transthoracic echocardiography (TTE) by trainees. To our knowledge, no study has evaluated the impact of the addition of price transparency to this education and feedback model on TTE utilization by resident physicians. We performed an education and feedback quality improvement initiative combining charge transparency data with information on AUC. We hypothesized that the initiative would reduce the number of complete TTE ordered and increase the number of limited TTE ordered, anticipating there would be substitution of limited for complete studies. Residents rotating on inpatient teaching cardiology ward teams received education on AUC for TTE, indications for limited TTE, and hospital charges for TTE. Feedback was provided on the quantity and charges for complete and limited TTE ordered by each team. We analyzed the effects of the intervention using a linear mixed effects regression model to adjust for potential confounders. The post-intervention weeks showed a reduction of 4.6 complete TTE orders per 100 patients from previous weekly baseline of 31.3 complete TTE orders per 100 patients (p value = 0.012). Charges for complete TTE decreased $122 from baseline of $980 per patient (p value = 0.040) on a per-week basis. Secondarily, there was no statistically significant change in limited TTE ordering during the intervention period. This initiative shows the feasibility of a house staff-driven charge transparency and education/feedback initiative that decreased medical residents' ordering of inpatient TTE.

Interactive role of diastolic dysfunction and ventricular remodeling in asymptomatic subjects at increased risk of heart failure Abstract Diastolic dysfunction (DD) and left ventricular remodeling (LVR) characterize patients at risk for heart failure (HF). To assess the prognostic impact of different diastolic function algorithms and a complex LVR classification (CRC) in asymptomatic subjects with preserved ejection fraction (EF) at risk for HF. We analyzed 1923 asymptomatic patients (male 43%; age 57, 33–76 years) with at least one cardiovascular risk factor and preserved (> 50%) EF. We used three algorithms for LV diastolic function assessment (Paulus et al. in Eur Heart J 28(20):2539–2550, 2007; Nagueh et al. in J Am Soc Echocardiogr 22(2):107–133, 2009, Eur Heart J Cardiovasc Imaging 17(12):1321–1360, 2016), and two algorithms for LVR (classic and CRC). We considered a composite end-point: cardiac death and hospitalization for HF. The highest presence of DD was diagnosed by Nagueh 2009 (211, 11%), while the prevalence according to Nagueh 2016 (63 patients, 3.2%) turned out to be the lowest (p < 0.001 vs the other algorithms). According to CRC, 780 (48.6%) patients had normal or physiologic hypertrophy, 298 (15.5%) concentric remodeling, 85 (4.4%) eccentric remodeling, 294 (15.3%) concentric hypertrophy, 39 (2%) mixed hypertrophy, 80 (4.1%) dilated hypertrophy, 73 (3.7%) eccentric hypertrophy and 294 (15.3%) were unclassifiable. After 39-month follow-up (261 events, 13.6%), Cox-regression (adjusted for age, gender, history of stable ischemic heart disease, classic remodeling classification) identified CRC (p = 0.01) and Nagueh 2016 (p < 0.001) as independent predictors of end-point. The coexistence of an adverse LVR by CRC and DD by Nagueh 2016 was associated with the worst prognosis. A concurrent structural (CRC) and functional (Nagueh Op. Cit) analysis improves prognostic stratification in asymptomatic subjects at risk for HF with preserved EF.

Procedural findings and early healing response after implantation of a self-apposing bioresorbable scaffold in coronary bifurcation lesions Abstract We aimed to evaluate feasibility, early healing and self-correcting properties of the Desolve 150 bioresorbable scaffold (BRS) implanted in bifurcation lesions, using the simple, provisional side branch (SB) stenting technique. BIFSORB pilot was a proof-of-concept study enrolling 10 patients with stable angina pectoris and a bifurcation lesion with SB ≥ 2.5 mm and less than 50% diameter stenosis. Procedure and 1-month outcome was evaluated by optical coherence tomography (OCT) to assess scaffold performance and healing patterns. Nine patients were treated with Desolve 150 BRS and one delivery to the target bifurcation failed. Thrombus formation in the jailed SB ostium was seen in three cases, but was completely resolved at 1-month. OCT confirmed acute self-correcting properties. No clinical events were reported after six months. Scaffold diameter by OCT increased in the proximal main vessel from 3.09 ± 0.16 mm to 3.34 ± 0.18 mm (p = 0.01) and in distal main vessel from 2.82 ± 0.26 mm to 3.02 ± 0.29 mm (p < 0.01) at one-month follow-up. SB ostial diameter stenosis improved from 42 ± 15% to 34 ± 12% (p = 0.01). Malapposition was effectively reduced after 1 month from 4.1 (1.4; 6.1)% to 0.1 (0; 0.6)% (p = 0.002). Treatment of bifurcation lesions using Desolve 150 BRS was feasible except for a delivery failure and unsettling thrombus formation behind jailing SB struts, which was completely resolved at 1-month. Self-correcting and even self-expanding properties were confirmed.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com