Cardiac magnetic resonance imaging in the evaluation and management of mitral valve prolapse - a comprehensive review.

Mitral valve prolapse is a common valve disorder that usually has a benign prognosis unless there is significant regurgitation or LV impairment. However, a subset of patients are at an increased risk of ventricular arrhythmias and sudden cardiac death, which has led to the recognition of "arrhythmic mitral valve prolapse" as a clinical entity. Emerging risk factors include mitral annular disjunction and myocardial fibrosis. While echocardiography remains the primary method of evaluation, cardiac magnetic resonance has become crucial in managing this condition. Cine magnetic resonance sequences provide accurate characterization of prolapse and annular disjunction, assessment of ventricular volumes and function, identification of early dysfunction and remodeling, and quantitative assessment of mitral regurgitation when integrated with flow imaging. However, the unique strength of magnetic resonance lies in its ability to identify tissue changes. T1 mapping sequences identify diffuse fibrosis, in turn related to early ventricular dysfunction and remodeling. Late gadolinium enhancement sequences detect replacement fibrosis, an independent risk factor for ventricular arrhythmias and sudden cardiac death. There are consensus documents and reviews on the use of cardiac magnetic resonance specifically in arrhythmic mitral valve prolapse. However, in this article, we propose an algorithm for the broader use of cardiac magnetic resonance in managing this condition in various scenarios. Future advancements may involve implementing techniques for tissue characterization and flow analysis, such as 4D flow imaging, to identify patients with ventricular dysfunction and remodeling, increased arrhythmic risk, and more accurate grading of mitral regurgitation, ultimately benefiting patient selection for surgical therapy.

Concordance of left ventricular volumes and function measurements between two human readers, a fully automated AI algorithm, and the 3D heart model.

Background: Echocardiography is essential in cardiovascular medicine for screening, diagnosis, and monitoring. Artificial intelligence (AI) has the potential to improve echocardiography by reducing variability and analysis time. While 3D echocardiography is becoming more accurate, 2D imaging still dominates clinical care. We aimed to evaluate agreement in measures of left ventricular (LV) volumes and function between human readers, a fully automated AI 2D algorithm, and the 3D Heart Model. Methods: A retrospective analysis was conducted on 109 patients who underwent 2D and 3D transthoracic echocardiography. LV end-diastolic and end-systolic volumes (LVEDV, LVESV) and ejection fraction (LVEF) were measured by two operators, a commercially available AI algorithm (US2ai), and the 3D Heart Model. Global longitudinal strain (GLS) was measured by the integrated semi-automated software and the AI algorithm. Outcomes included measures of agreement [bias, limit of agreement and Pearson's correlation (R)]. Results: For LV volume measurements, the AI algorithm was strongly correlated with the average of the human operators (r = 0.89 for LVEDV and r = 0.92 for LVESV), which was higher than between the operators (r = 0.74 and r = 0.84, respectively, p < 0.01). The same trend was seen for measures of reliability with respect to LVEDV, but not LVESV. AI demonstrated comparable performance to human operators in measuring LVEF, while the 3D Heart Model had a weaker correlation and reliability compared with human operators and AI measurements. The correlation between human operators and AI for GLS was only moderate. Conclusion: This study demonstrates AI-based echocardiography as a promising tool for accurately assessing LV volumes and LVEF in clinical practice. AI-based measures demonstrated a significantly lower inter-operator variability, thereby improving the consistency and reliability of these assessments. Moreover, AI may prove particularly effective for conducting retrospective bulk analyses, offering a valuable tool for comprehensive evaluations of past data.

Cardiovascular Disease from Pathophysiology to Risk Estimation: Is Inflammation Estimated through Perivascular Attenuation on Computed Tomography the Key?

(1) Background: Systemic inflammation stands as a well-established risk factor for ischemic cardiovascular disease, as well as a contributing factor in the development of cardiac arrhythmias, notably atrial fibrillation. Furthermore, scientific studies have brought to light the pivotal role of localized vascular inflammation in the initiation, progression, and destabilization of coronary atherosclerotic disease. (2) Methods: We comprehensively review recent, yet robust, scientific evidence elucidating the use of perivascular adipose tissue attenuation measurement on computed tomography applied to key anatomical sites. Specifically, the investigation extends to the internal carotid artery, aorta, left atrium, and coronary arteries. (3) Conclusions: The examination of perivascular adipose tissue attenuation emerges as a non-invasive and indirect means of estimating localized perivascular inflammation. This measure is quantified in Hounsfield units, indicative of the inflammatory response elicited by dense adipose tissue near the vessel or the atrium. Particularly noteworthy is its potential utility in assessing inflammatory processes within the coronary arteries, evaluating coronary microvascular dysfunction, appraising conditions within the aorta and carotid arteries, and discerning inflammatory states within the atria, especially in patients with atrial fibrillation. The widespread applicability of perivascular adipose tissue attenuation measurement underscores its significance as a diagnostic tool with considerable potential for enhancing our understanding and management of cardiovascular diseases.

Editing of 3D images in echocardiographic evaluation of mitral valve: Is there any correlation with photography?

Editing of 3D raw images acquired during transesophageal echocardiography could be similar to the post processing of raw images with digital software used in photography. 3D image editing in echocardiography is often underestimated in clinical practice, and people are satisfied with the first 3D image they are able to obtain during transesophageal examination. In fact, it is often believed to represent solely an aesthetic addition that does not change the information already obtained with 2D and baseline 3D. In reality, it represents a crucial moment to better understand the mechanisms of mitral pathology, avoiding artifacts and misjudgments. The importance of acquiring raw 3D images of the valve having all the necessary information (ring, the leaflet in toto, the right frame rate) allows us then to edit them making them more beautiful and clearer from the point of view of the information received. Nevertheless, by exclusively acquiring a raw 3D with all the necessary information, we can quickly finish the transesophageal examination, reducing its duration and discomfort for the patient, as well as the inherent risk of complications related to the procedure per se.

Rest contrast echocardiography unmasks hidden wall motion abnormalities in patients with chest pain. A case series and review of pertinent literature.

We present a case series of three patients that underwent myocardial contrast echocardiography (MCE) in the setting of recent chest pain, as paradigmatic examples of the usefulness of contrast-echocardiography with very-low mechanical index imaging in the context of rest wall motion assessment. Moreover, we analysed the pertinent literature about the use of rest MCE in the context of chest pain of unknown origin, showing its diagnostic and prognostic impact. We think that MCE could play a key role in detecting chest pain subtended by previously unknown coronary artery disease (CAD). For example, in pts without significant electrocardiogram (ECG) modifications or in whom high sensitivity troponins show only borderline increase (still below the upper limit) or have no clearly significant delta. In such cases the more sensitive evaluation of wall motion (WM) powered by MCE could add diagnostic information, above all in pts with severe CAD but apparently normal WM at standard echocardiography.

Myocardial Scar by Pulse-Cancellation Echocardiography Is Independently Associated with Appropriate Defibrillator Intervention for Primary Prevention after Myocardial Infarction.

BACKGROUND: Myocardial scar burden impacts prognosis in patients with coronary artery disease who have experienced a myocardial infarction (MI). This has been demonstrated by late gadolinium enhancement cardiac magnetic resonance. Clinical experience with echocardiography suggests that the reflected ultrasound signal is enhanced in infarcted myocardial segments. Scar imaging with an ultrasound multipulse scheme (eScar) has been preliminarily validated in prior studies. OBJECTIVE: To assess whether scar burden, as detected by eScar, is associated with implantable cardioverter-defibrillator (ICD) shocks in post-MI patients. METHODS: We retrospectively selected 50 post-MI patients with an ejection fraction <35% who received an ICD for primary prevention and subsequently had at least one appropriate shock (cases). These were compared with 50 post-MI patients, matched for clinical variables and ejection fraction, who never experienced an appropriate defibrillator shock (controls). Subjects were assessed with the eScar technique at the time of implantation or during follow-up. RESULTS: An eScar was present in ≥1 segment in 40 of 50 (80%) cases vs 26 of 50 (52%) controls and was associated with appropriate ICD shocks (P = .004). Receiver operating characteristic curve analysis, using a threshold of ≥3 segments by eScar, showed an area under the curve (AUC) of 0.715. On models including clinical and echocardiographic variables, eScar remained significantly associated with ICD shocks (P = .050 or P = .033 depending on the model). Adding eScar to a multivariate logistic regression model including indexed left ventricular end-systolic volume led to an increase in AUC from 0.734 to 0.782 (P = .049), while substituting indexed left ventricular end-diastolic volume for indexed left ventricular end-systolic volume resulted in a nonsignificant increase in AUC from 0.747 to 0.785 (P = .098). CONCLUSIONS: Presence and extent of eScar were independently associated with appropriate ICD shocks in this study of patients with prior MI and reduced ejection fraction. However, the addition of eScar assessment to the clinical multivariable model that included also indexed left ventricular end-diastolic volume did not provide significant incremental value.

Visually assessed coronary and cardiac calcium outperforms perfusion data during scintigraphy in the prediction of adverse outcomes.

OBJECTIVES: To determine whether calcifications of the coronary arteries (coronary artery calcium 0 to 4 score), or extending the assessment also to cardiac valves and thoracic aorta (overall calcium 0 to 8 score), as seen on computed tomography for attenuation correction during stress-scintigraphy (SPECT-CT), are associated with total mortality and non-fatal myocardial infarction. We aimed to assess whether these calcifications added to the prognostic value of SPECT imaging. BACKGROUND: The presence/amount of calcium in the coronary arteries, but also in the heart valves and aorta, has been associated with cardiovascular (CV) and all-cause mortality. This information can be obtained during SPECT-CT examinations, where low resolution CT images are co-registered for attenuation correction of myocardial perfusion, but then discarded. METHODS: Clinical data were collected on 353 consecutive patients submitted to stress SPECT-CT between Sept 2010 and Oct 2012, for suspected coronary artery disease (CAD). Follow-up data on outcomes were collected retrospectively. RESULTS: Mean age was 72 and 58% were male. Mean follow-up was 6.4 years, during which 48 subjects died (15 from CV causes) and 10 had non-fatal myocardial infarction (MI). Reversible perfusion defects were detected in 55 patients (15.6%), 39 of whom (11%) had >mild defects. The presence of a calcium score > 1 in the attenuation correction images was the strongest univariate predictor of all-cause death or MI (hazard ratio 7.21, p < .001). On multivariate analysis, controlling for age, gender and myocardial perfusion defects an overall calcium score > 2 remained a predictor of all-cause death or non-fatal MI (hazard ratio 4.12, p < .001). CONCLUSIONS: Visual assessment of coronary or overall coronary, cardiac and aortic calcium in the CT images used for attenuation correction during SPECT-CT is feasible and reproducible. It was strongly associated with all-cause death and MI, even after controlling for clinical variables and myocardial perfusion data. This simple visual calcium assessment does not add additional costs or radiation, and may significantly improve risk-assessment of patients with suspected CAD undergoing SPECT-CT. CONDENSED ABSTRACT: Calcium in the coronary arteries, heart valves and aorta has been associated with worse prognosis. We sought to determine whether assessment of such calcifications on computed tomography images (co-registered for myocardial perfusion attenuation correction and then discarded) are independently associated with long-term outcome on top of available data. We enrolled 353 consecutive patients, referred for suspected coronary artery disease. An overall calcium score > 1 in the attenuation correction images was the strongest univariate (hazard ratio 7.21, p < .001) and multivariate predictor of all-cause death or non-fatal MI (hazard ratio 4.12, p < .001), even after controlling for clinical variables and myocardial perfusion data.

Coronary Flow Velocity Reserve Reduction Is Associated with Cardiovascular, Cancer, and Noncancer, Noncardiovascular Mortality.

BACKGROUND: Coronary flow velocity reserve (CFVR) measured in the left anterior descending artery during high-dose vasodilator stress echocardiography interrogates both epicardial and microcirculatory coronary function and has been inversely associated with chronic inflammation and microvascular dysfunction, as well as with the presence of obstructive coronary artery disease. Microvascular dysfunction and chronic inflammation are common mechanisms of disease in cardiovascular (CV) and non-CV conditions. We aimed to assess whether CFVR is associated with all-cause death, but more specifically with CV, cancer, and non-CV and noncancer (NCVNC) mortality, independently and increasingly over other demographic, clinical, and echocardiography variables. METHODS: One thousand two patients who underwent stress echocardiography were followed for a median of 8.2 years, with clinical, regional wall motion abnormalities (RWMAs), and CFVR data. The independent prognostic value of RWMA and CFVR regarding CV, cancer, or NCVNC mortality was evaluated adjusting for clinical variables. A prespecified subgroup of subjects with no RWMA or revascularization procedures during follow-up was also analyzed (n = 752), to exclude most participants with possible coronary artery disease and remove such confounding from the assessment of the potential association of CFVR and mortality. RESULTS: A total of 161 patients (16%) died, 63 deaths being CV (39%), 52 from cancer (32%), and 46 (29%) from NCVNC causes. In comparison to CV mortality, cancer and NCVNC mortality were not associated with an ischemic RWMA at univariable analysis, while a CFVR < 2 was significantly associated with each category of cause-specific mortality. A CFVR < 2 or ≥2 separated a group of patients with 8-year 14.6% versus 1.2% CV mortality, 10.3% versus 0.4% cancer mortality, and 9.5% versus 1.5% NCVNC mortality. CONCLUSIONS: The reduction of CFVR is independently associated with CV, cancer, and NCVNC death in a population clinically referred for suspected/known coronary artery disease. CFVR can act as a marker or a mechanism preceding and predicting mortality from a wide variety of diseases.

Sighting acute myocardial infarction through platelet gene expression.

Acute myocardial infarction is primarily due to coronary atherosclerotic plaque rupture and subsequent thrombus formation. Platelets play a key role in the genesis and progression of both atherosclerosis and thrombosis. Since platelets are anuclear cells that inherit their mRNA from megakaryocyte precursors and maintain it unchanged during their life span, gene expression profiling at the time of an acute myocardial infarction provides information concerning the platelet gene expression preceding the coronary event. In ST-segment elevation myocardial infarction (STEMI), a gene-by-gene analysis of the platelet gene expression identified five differentially expressed genes: FKBP5, S100P, SAMSN1, CLEC4E and S100A12. The logistic regression model used to combine the gene expression in a STEMI vs healthy donors score showed an AUC of 0.95. The same five differentially expressed genes were externally validated using platelet gene expression data from patients with coronary atherosclerosis but without thrombosis. Platelet gene expression profile highlights five genes able to identify STEMI patients and to discriminate them in the background of atherosclerosis. Consequently, early signals of an imminent acute myocardial infarction are likely to be found by platelet gene expression profiling before the infarction occurs.

Everything in the "right" place: multifocal transient ST segment elevation in patient with single coronary artery arising from the right Valsalva sinus.

Single coronary artery (SCA) is a rare coronary anomaly that occurs with an incidence of 0.024%. We report the case of an 83-year-old woman with a Lipton's type 3 SCA, which is the rarest anomaly within this group, occurring only in the 0.004% of general population.  The clinical presentation of this patient was chest pain at rest with multifocal transient ST segment elevation as a marker of multifocal ischemia secondary to severe three vessels coronary artery disease (CAD). This patient was proposed for coronary artery bypass grafting (CABG) with an excellent mid-term outcome.