Potential utility of myocardial blood flow quantification with single photon emission computed tomography in a patient undergoing treatment for breast cancer.

Diagnosis and management of cardiac complications of cancer treatment can be challenging. Few PET data suggest a potential role of dynamic perfusion imaging with measurements of absolute myocardial blood flow and flow reserve (MFR). We report the case of a 72-year-old woman with a history of bilateral breast cancer who underwent dynamic cardiac scintigraphy. Relative perfusion analysis was normal, whereas MFR was impaired in all territories suggesting diffuse microvascular dysfunction. Flow parameters derived from dynamic cardiac scintigraphy could thus be an interesting tool in cardio-oncology.

QRS-T angle: is it a specific parameter associated with sudden cardiac death in type 2 diabetes? Results from the SURDIAGENE and the Mini-Finland prospective cohorts.

AIMS/HYPOTHESIS: Type 2 diabetes is associated with a high risk of sudden cardiac death (SCD), but the risk of dying from another cause (non-SCD) is proportionally even higher. The aim of the study was to identify easily available ECG-derived features associated with SCD, while considering the competing risk of dying from non-SCD causes. METHODS: In the SURDIAGENE (Survie, Diabete de type 2 et Genetique) French prospective cohort of individuals with type 2 diabetes, 15 baseline ECG parameters were interpreted among 1362 participants (mean age 65 years; HbA1c 62±17 mmol/mol [7.8±1.5%]; 58% male). Competing risk models assessed the prognostic value of clinical and ECG parameters for SCD after adjusting for age, sex, history of myocardial infarction, N-terminal pro b-type natriuretic peptide (NT-proBNP), HbA1c and eGFR. The prospective Mini-Finland cohort study was used to externally validate our findings. RESULTS: During median follow-up of 7.4 years, 494 deaths occurred including 94 SCDs. After adjustment, frontal QRS-T angle ≥90° (sub-distribution HR [sHR] 1.68 [95% CI 1.04, 2.69], p=0.032) and NT-proBNP level (sHR 1.26 [95% CI 1.06, 1.50] per 1 log, p=0.009) were significantly associated with a higher risk of SCD. Nevertheless, frontal QRS-T angle was the only marker not to be associated with causes of death other than SCD (sHR 1.08 [95% CI 0.84, 1.39], p=0.553 ). These findings were replicated in the Mini-Finland study subset of participants with diabetes (sHR 2.22 [95% CI 1.05, 4.71], p=0.04 for SCD and no association for other causes of death). CONCLUSIONS/INTERPRETATION: QRS-T angle was specifically associated with SCD risk and not with other causes of death, opening an avenue for refining SCD risk stratification in individuals with type 2 diabetes.

Early survival after acute myocardial infarction with ST-segment elevation: What could be improved? Insights from France PCI French registry.

Early mortality post-ST-segment elevation myocardial infarction (STEMI) in France remains high. The multicentre France Percutaneous Coronary Intervention Registry includes every patient undergoing coronary angiography in France. We analyzed the prevalence and impact of unmodifiable and modifiable risk factors on 30-day survival in patients experiencing STEMI. Patients admitted for STEMI between 01/2014 and 12/2016 were included in the analysis. Patients with nonobstructive coronary artery disease, with cardiogenic shock or cardiac arrest without STEMI, were excluded. Prehospital, clinical and procedural data were collected prospectively by the cardiologist in the cath lab using medical reporting software. Information on outcomes, including mortality, was obtained by a dedicated research technician by phone calls or from medical records. Marginal Cox proportional hazards regression was used to test the predictive value for survival at 30 days in a multivariable analysis. Included were 2590 patients (74% men) aged 63 ± 14 years. During the first month, 174 patients (6.7%) died. After adjustment, unmodifiable variables significantly associated with reduced 30-day survival were: age > 80 years (prevalence 15%; hazard ratio [HR] 2.7; 95% confidence interval [CI] 1.5-4.7), chronic kidney disease (2%; HR 5.3; 95% CI 2.6-11.1), diabetes mellitus (14%; HR 1.6; 95% CI 1.0-2.5), anterior or circumferential electrical localization (39%; HR 2.0; 95% CI 1.4-2.9), and Killip class 2, 3, or 4 (7%; HR 3.4; 95% CI 1.9-5.9; 2%; HR 10.1; 95% CI 5.3-19.4; 4%; HR 18; 95% CI 10.8-29.8, respectively). Among modifiable variables, total ischemic time > 3 hours (68%; HR 1.8; 95% CI 1.1-3.0), lack of appropriate premedication (18%; HR 2.2; 95% CI 1.5-3.3), and post-PCI TIMI < 3 (6%; HR 4.9; 95% CI 3.2-7.6) were significantly associated with reduced 30-day survival. Most predictors of 30-day survival post-STEMI are unmodifiable, but outcomes might be improved by optimizing modifiable factors, most importantly ischemic time and appropriate premedication.

Does Aortic Valve Calcium Score Still Predict Death, Cardiovascular Outcomes, and Conductive Disturbances after Transcatheter Aortic Valve Replacement with New-Generation Prostheses?

BACKGROUND: The development of transcatheter aortic valve replacement (TAVR) has led to an improvement in morbidity-mortality in the treatment of severe aortic stenosis in patients at high surgical risk. However, the procedure is not free from life-threatening cardiovascular outcomes and conductive disturbances. The objective of our study was to analyze the prognostic impact of aortic valve calcium score on the occurrence of complications following the procedure. MATERIALS AND METHODS: Patients who have benefited from TAVR with the implantation of new-generation Sapien 3 and Evolut R aortic valve prostheses between January 2017 and July 2018 with the prior realization of a cardiac computed tomography with measurement of the aortic valve calcium score were retrospectively analyzed. Primary endpoint was a composite of death, stroke, and myocardial infarction within a period of 1 month after TAVR. Relation between valvular calcium and conductive disturbances was secondarily analyzed over the same period, and occurrences of high-degree atrioventricular block (paroxysmal or permanent), new-onset left bundle branch block, and the need for permanent or transient cardiac stimulation were associated with the secondary endpoint. RESULTS: Overall, 144 patients were included. The aortic valve calcium score was not significantly higher in patients who reached the primary endpoint (2936 ± 1235 vs. 3051 ± 1440, P = 0.93). Among the 106 patients analyzed after excluding subjects with a prior pacemaker or left bundle branch block, aortic valvular calcium score was not statistically associated with the occurrence of conduction disturbances (3210 ± 1436 vs. 2948 ± 1223, P = 0.31). CONCLUSION: Our results suggest that the measurement of aortic valve calcium score has no prognostic value regarding mortality, cardiovascular events, or conductive disturbances after TAVR using the new generation of valves.

Post-stEnting assessment of Re-endothelialization with optical Frequency domain imaging aftEr Chronic Total Occlusion procedure: The PERFE-CTO Study Design and Rationale.

BACKGROUND: The treatment of chronic total occlusion of coronary arteries by percutaneous coronary intervention (CTO PCI) is one of the most representative technical advances in ischemic cardiomyopathy of last decade. However, how the complex histopathological remodeling and the new techniques affect healing processes after stent implantation remains unknown. OBJECTIVE: The objective of the PERFE-CTO study is to analyze stent coverage, malapposition and other mechanical abnormalities 3 months after CTO recanalization using intravascular imaging. METHODS: In a French prospective interventional multicenter study, stent strut coverage, acquired malapposition and neointimal hyperplasia (NIH) proliferation will be systematically assessed with 3 months angiogram control and intracoronary optical frequency domain imaging (OFDI) after successful CTO PCI of >20 mm in length. The impact of routine systematical intracoronary imaging after these complex procedures will also be evaluated by measuring the rate of significant mechanical abnormalities (strut malapposition, edge dissection, thrombus) that was undetected by fluoroscopy alone and by complementary PCI when needed. Secondarily, these data will be compared according to clinical characteristics, antiplatelet therapy use or desobstruction technique (antegrade vs. retrograde, true lumen vs. subintima). Each patient will undergo a one-year clinical follow-up. A total of 150 analyzed CTO lesions is expected. CONCLUSION: The PERFE-CTO study will provide essential understanding of the early history after CTO recanalization and the identification of inadequate evolution (stent thrombosis, restenosis or late delayed stent endothelization and cardiovascular outcomes) using intravascular imaging to improve long-term CTO results.

Twenty-four-hour ambulatory ECG monitoring relevancy in myotonic dystrophy type 1 follow-up: Prognostic value and heart rate variability evolution.

BACKGROUND: Patient prognosis in type 1 myotonic dystrophy (DM1) is very poor. Annual 24-hour holter ECG monitoring is recommended but its relevance is debated. Main objective was to determine whether holter ECG parameters could predict global death in DM1 patients and secondarily to assess whether they could predict cardiovascular events and sudden cardiac death, to compare DM1 patients and healthy controls, and to assess their evolution in DM1 over a 5-year period. METHODS: This retrospective study included genetically confirmed DM1. Primary endpoint was global death. Secondary endpoints were labeled "sudden cardiac death" which was a composite of sudden cardiac death, aborted sudden cardiac death, implantable cardioverter defibrillator therapy, sustained ventricular tachycardia, atrioventricular block grade 3, pause >3 s; and "cardiovascular events" which was a composite of all-cause mortality, pacemaker or cardioverter defibrillator implantation, sustained ventricular tachycardia, supraventricular tachycardia, hospitalization for acute cardiac cause and heart failure. RESULTS: Forty-seven patients (22 women, 40 ± 13 years old) were included. Three (7%) DM1 patients died, 9 (19%) experienced "sudden cardiac death" endpoint and 21 (45%) experienced "cardiovascular event" endpoint during mean follow-up of 95 ± 22 months. None of holter ECG parameters were discriminant to predict death or secondary endpoints. Compared to healthy controls, DM1 patients had higher SDNN and LF/HF ratio. Finally, heart rate variability parameters remained stable over a mean interval of 61 ± 15 months excepting pNN50 which decreased significantly. CONCLUSION: Results suggest that annually-repeated holter ECG in DM1 is not useful for stratifying risk of sudden death and cardiovascular outcomes.

Acquired Systemic-to-pulmonary Venous Shunt or Persistent Left Superior Vena Cava? A Rare Right-to-left Shunt Case-based Discussion.

Cardiac shunts are often described in congenital or pediatric populations, but systemic-to-pulmonary venous shunts in adult patients are reported in literature in isolated case reports. We present the case of a 70-year-old female with a left superior vena cava (SVC) draining into the left atrium by the left superior pulmonary vein, with a complete right-to-left shunt of the superior venous circulation caused by a former catheter thrombosis in the right SVC. Diagnosis was suspected after a contrast echocardiography showing an exclusive perfusion of left heart after intravenous injection and confirmed by helical computed tomography with three-dimensional reconstruction. After medico-surgical discussion, a first-line conservative treatment with oxygen therapy was chosen, due to the stability of symptoms and high predicted risk of perioperative mortality. The particularities of this case are that we cannot determine if the origin of this shunt is a latent persistent left SVC becoming symptomatic after the SVC obstruction or an abnormal collateral pathway due to the thrombosis and the unusual indirect communication through a pulmonary vein.