Role of Cardiac Magnetic Resonance Imaging in Myocardial Infarction.

PURPOSE OF REVIEW: The purpose of the present paper is to analytically review the diagnostic and prognostic role of CMR in ST-segment elevation myocardial infarction (STEMI) survivors. Percutaneous coronary intervention (PCI) is the treatment of choice in patients STEMI. However, risk of future events remains substantial. Assessment of the extent of myocardial infarction (MI), cardiac function and ventricular remodelling has become the focus of recent studies. Electrocardiography, angiography and echocardiography parameters, as well as risk scores, lack sensitivity and reproducibility in predicting future cardiovascular events. A major advantage of cardiac magnetic resonance imaging (CMR) is that it provides myocardial tissue characterization. RECENT FINDINGS: CMR is able to quantify both reversible and irreversible myocardial injury and correlates with future events. This review will illustrate how microvascular function indices (myocardial salvage index, presence and amount of microvascular obstruction and intramyocardial haemorrhage) detectable by CMR add prognostic information and could impact on future strategies to improve outcomes in revascularized patients.

[Polycitemia vera and pulmonary embolism: case report]. / Policitemia vera ed embolia polmonare: caso clinico.

Pulmonary embolism is a rare clinical onset of chronic myeloproliferative diseases. Early diagnosis is very important because medical therapy reduces both mortality and morbility. We describe a case of pulmonary embolism as clinical onset of an unknown myeloproliferative disorder. On the basis of our experience is very important early diagnosis and therapy to reduce incidence of later major thrombotic complications.

Cardiac magnetic resonance features of left dominant arrhythmogenic cardiomyopathy: differential diagnosis with myocarditis.

Cardiac magnetic resonance (CMR) findings suggesting a suspected left-dominant arrhythmogenic cardiomyopathy (LDAC) may be difficult to distinguish from those related to previous myocarditis; however, especially in patients with ventricular arrhythmias (VA) with ECG morphology consistent with a left ventricle (LV) origin differential diagnosis is fundamental. Aim of the study was to identify potential imaging features at CMR specific for LDAC diagnosis. Between January 2011 and December 2019, we enrolled 15 consecutive stable patients with a recent diagnosis of significant VA and ECG morphology consistent with a LV origin, detection of potential LV arrhythmic substrate at CMR and undergoing a clinically-indicated LV endomyocardial biopsy showing tissue abnormalities consistent with the diagnosis of LDAC. From the same CMR-endomyocardial biopsy registry, a second group of 30 consecutive patients who underwent CMR and biopsy with a histological diagnosis of previous myocarditis were identified. (1) Subepicardial LGE at the level of the posterolateral wall of the LV was detected in 13 cases of LDAC vs. 21 cases of myocarditis; (2) fat infiltration, and particularly subepicardial posterolateral fat infiltration, was found in almost all LDAC patients vs. one myocarditis only (p < 0.01). (3) No differences in other CMR findings or in any clinical or echocardiographic parameters were found between patients with a biopsy consistent with LDAC vs. myocarditis. In patients with significant VA and ECG morphology consistent with a LV origin, the presence of morpho-functional involvement of the subepicardial layer of LV posterolateral wall at CMR (LGE, fat infiltration, wall dyskinesis) supports LDAC diagnosis.

The PFO anatomy evaluation as possible tool to stratify the associated risks and the benefits arising from the closure.

AIMS: According to the current guidelines, the patent foramen ovale (PFO) is still considered a qualitative factor and, as a consequence, its closure is recommended just on the basis of its 'presence'. METHODS AND RESULTS: In the year 2008, we evaluated 25 patients (mean age 62.7) with acute cerebrovascular event and 92 patients (mean age 27.3) suffering from migraine with aura. No PFO was reported in 79 patients. A venous-to-arterial circulation shunt had been shown in 38 patients (29 subjects with migraine and 9 subjects with prior stroke). According to the number of microbubbles arrived during the Valsava manoeuvre, we found: 25 small PFO, 6 moderate PFO, and 6 severe PFO. In the baseline population with migraine (n = 92), 32% (n = 29) had a PFO. A 'large' foramen was reported in approximately 9% of the migraine subjects. In the population with prior stroke (n=25), 9 patients (36%) had a PFO. A 'large' foramen was reported in 45% of the patients with ischaemic stroke. We found embryonic recesses in 13% (n = 4) of the patients with migraine and PFO (n=29) vs. 66% (n=6) of the patients with ischaemic stroke and PFO (P= 0.01). CONCLUSION: It is possible to suppose that not all PFO have the same prognostic value. The evaluation of two anatomical characteristics can allow to identify those foramina at higher risk and, as a consequence, the patients who could have a major benefit from the closure.

Impact of preclinical carotid atherosclerosis on global cardiovascular risk stratification and events in a 10-year follow-up: comparison between the algorithms of the Framingham Heart Study, the European SCORE and the Italian 'Progetto Cuore'.

BACKGROUND: The aim of the study was to compare three widely used algorithms for stratification of the global cardiovascular risk (GCVR): the Framingham Heart Study (FHS) score, the European systemic coronary risk estimation (SCORE) and the Italian 'Progetto Cuore' (heart project) score. It was also investigated how preclinical carotid atherosclerosis (pre-ATS) might influence the incidence and improve the risk prediction of cerebrovascular and cardiovascular events. METHODS: Subjects (n = 358) without previous history of cardiovascular disease (CVD) were recruited and the GCVR was calculated for each patient. An ultrasound evaluation of the carotid arteries was also performed. RESULTS: According to SCORE, the recruited population had globally a low risk of cardiovascular mortality and the risk equation estimated a GCVR of 2% in spite of the in spite of the observed rate of 0.8% (95% CI -0.001 to 0.02) of fatal events. The FHS and the 'Progetto Cuore' risk equations, regarding a 10-year risk of fatal and nonfatal events, predicted a low GCVR of 31 and 30%, an intermediate risk of 64 and 66%, and a high risk of 5 and 4% of the population respectively. They also estimated a general GCVR of 6.9 and 6.4% respectively versus an observed event rate 27.7 (95% CI 23.0 to 32.0). The discriminative power, calculated with the area under the receiving operator curve (AUROC), was 0.53 for SCORE, 0.54 for FHS and 0.55 for Progetto Cuore. Based on the ultrasound evaluation of carotid arteries, a first clinical event at 10-year follow-up was reported in 3% of subjects with normal ultrasound examination, 32% with intima-media thickening (IMT) and 62% with asymptomatic carotid plaque (ACP). CONCLUSION: The present study has evaluated for the first time the prediction of GCVR in an asymptomatic population, comparing three different risk scores. Carotid pre-ATS was related to the major cardiovascular risk factors (RFs) and was independently associated with a major incidence of cerebro- and cardiovascular events, therefore enhancing the predictive value of the three different risk scores.

Prognostic Value and Therapeutic Perspectives of Coronary CT Angiography: A Literature Review.

Coronary stenosis severity is both a powerful and a still debated predictor of prognosis in coronary artery disease. Coronary computed tomographic angiography (CCTA) has emerged as a noninvasive technique that enables anatomic visualization of coronary artery disease (CAD). CCTA with newer applications, plaque characterization and physiologic/functional evaluation, allows a comprehensive diagnostic and prognostic assessment of otherwise low-intermediate subjects for primary prevention. CCTA measures the overall plaque burden, differentiates plaque subtypes, and identifies high-risk plaque with good reproducibility. Research in this field may also advance towards an era of personalized risk prediction and individualized medical therapy. It has been demonstrated that statins may delay plaque progression and change some plaque features. The potential effects on plaque modifications induced by other medical therapies have also been investigated. Although it is not currently possible to recommend routinely serial scans to monitor the therapeutic efficacy of medical interventions, the plaque modulation, as a part of risk modification, appears a feasible strategy. In this review we summarize the current evidence regarding vulnerable plaque and effects of lipid lowering therapy on morphological features of CAD. We also discuss the potential ability of CCTA to characterize coronary atherosclerosis, stratify prognosis of asymptomatic subjects, and guide medical therapy.

QT-interval evaluation in primary percutaneous coronary intervention of ST-segment elevation myocardial infarction for prediction of myocardial salvage index.

Assessing the efficacy of revascularization therapy in patients with ST-segment elevation myocardial infarction (STEMI) is extremely important in order to guide subsequent management and assess prognosis. We aimed to determine the relationship between corrected QT-interval (QTc) changes on standard sequential ECG and myocardial salvage index in anterior STEMI patients after successful primary percutaneous coronary intervention. Fifty anterior STEMI patients treated by primary percutaneous coronary intervention underwent quantitative ECG analysis and cardiac magnetic resonance. For each patient the difference (ΔQTc) between the QTc of ischemic myocardium (maximum QTc in anterior leads) versus remote myocardium (minimum QTc in inferior leads) during the first six days after STEMI was measured. The QTc in anterior leads was significantly longer than QTc in inferior leads (p<0.0001). At multivariate analysis, ΔQTC and peak troponin I were the only independent predictors for late gadolium enhancement while ΔQTc and left ventricular ejection fraction were independent predictors of myocardial salvage index <60%. The receiver operative curve of ΔQTc showed an area under the curve of 0.77 to predict a myocardial salvage index <0.6. In conclusion, in a subset of patients with a first occurrence of early revascularized anterior STEMI, ΔQTc is inversely correlated with CMR-derived myocardial salvage index and may represent a useful parameter for assessing efficacy of reperfusion therapy.

Fractional flow reserve: lessons from PLATFORM and future perspectives.

In the treatment of stable coronary artery disease (CAD) the identification of patients who may gain the highest benefit from further invasive treatments is of pivotal importance for the healthcare system. In this setting, it has been established that an ischemia-guided revascularization strategy yields improved clinical outcomes in a cost-effective fashion compared with anatomy-guided revascularization alone. Invasive fractional flow reserve (FFR) is considered the gold standard, especially in the intermediate-range atherosclerotic lesions, for assessing lesion specific ischemia at the time of invasive coronary angiography and has now become the standard of reference for studies assessing the diagnostic performance of the various non-invasive stress tests. Coronary computed tomography angiography (cCTA) is an increasingly utilized non-invasive test that enables direct anatomical visualization of CAD in the epicardial coronary arteries with excellent sensitivity and negative predictive value. However, cCTA alone has poor specificity with FFR. With advances in computational fluid dynamics, it is possible to derive FFR from cCTA datasets improving its positive predictive value and specificity. The aim of this review is to summarize the technical aspects of FFR-CT, clinical evidence and limitations behind the novel technology, with a special focus on the recent PLATFORM Trial analyzing the effectiveness, clinical outcomes and resource utilization of FFR-CT. Finally, the future perspective of FFR-CT will be presented.

[Horizons and perspectives on the problem of non--responders to cardiac resynchronization therapy.] / Focus sui non responder alla terapia di resincronizzazione cardiaca: orizzonti e prospettive.

Cardiac resynchronization therapy (CRT) has been shown as a successful strategy in the treatment of patients with heart failure and electrical dyssincrony. However, a significant proportion of implanted patients fails to respond sufficiently or in a predictable manner. Consequently, non response to CRT remains a valuable problem in clinical practice. In order to improve CRT response and long-term clinical benefits, the proper evaluation of patient's global frialty, the technology improvement, the multimodality imaging approach and the use of simple and low cost electrographic parameters (to verify effective biventricular capture and QRS narrowing) could play a important role. Therefore, the integration of various medical expertises (clinical cardiology, cardiac advanced imaging, electrophysiology) is a crucial element in order to achive the maximal benefits from this promising tecnique. In the multistep process (from patients evaluation to results verification) the follow-up even from the earliest post implantation phase, should be managed with great attention having the potential for impact the prognosis. This brief review focus the problem of non responder to CRT, giving particular attention to the different variables that may play a role (comorbilities, improvement in the tecnology of device implantation, role of multimodality imaging and electrocardiographic parameters).

Prognostic Stratification of Patients With ST-Segment-Elevation Myocardial Infarction (PROSPECT): A Cardiac Magnetic Resonance Study.

BACKGROUND: Cardiac magnetic resonance (CMR) is a robust tool to evaluate left ventricular ejection fraction (LVEF), myocardial salvage index, microvascular obstruction, and myocardial hemorrhage in patients with ST-segment-elevation myocardial infarction. We evaluated the additional prognostic benefit of a CMR score over standard prognostic stratification with global registry of acute coronary events (GRACE) score and transthoracic echocardiography LVEF measurement. METHODS AND RESULTS: Two hundred nine consecutive patients with ST-segment-elevation myocardial infarction (age, 61.4±11.4 years; 162 men) underwent transthoracic echocardiography and CMR after succesful primary percutaneous coronary intervention. Major adverse cardiac events (MACE) were assessed at a mean follow-up of 2.5±1.2 years. MACE occurred in 24 (12%) patients who at baseline showed higher GRACE risk score (P<0.01), lower LVEF with both transthoracic echocardiography and CMR, lower myocardial salvage index, and higher per-patient myocardial hemorrhage and microvascular obstruction prevalence and amount as compared with patients without MACE (P<0.01). The best cut-off values of transthoracic echocardiography-LVEF, CMR-LVEF, myocardial salvage index, and microvascular obstruction to predict MACE were 46.7%, 37.5%, 0.4, and 2.6% of left ventricular mass, respectively. Accordingly, a weighted CMR score, including the following 4 variables (CMR-LVEF, myocardial salvage index, microvascular obstruction, and myocardial hemorrhage), with a maximum of 17 points was calculated and included in the multivariable analysis showing that only CMR score (hazard ratio, 1.867 per SD increase [1.311-2.658]; P<0.001) was independently associated with MACE with the highest net reclassification improvement as compared to GRACE score and transthoracic echocardiography-LVEF measurement. CONCLUSIONS: CMR score provides incremental prognostic stratification as compared with GRACE score and transthoracic echocardiography-LVEF and may impact the management of patients with ST-segment-elevation myocardial infarction.

Non-responders to cardiac resynchronization therapy: Insights from multimodality imaging and electrocardiography. A brief review.

BACKGROUND: Cardiac resynchronization therapy (CRT) is a successful strategy for heart failure (HF) patients. The pre-requisite for the response is the evidence of electrical dyssynchrony on the surface electrocardiogram usually as left bundle branch block (LBBB). Non-response to CRT is a significant problem in clinical practice. Patient selection, inadequate delivery and sub-optimal left ventricle lead position may be important causes. OBJECTIVES: In an effort to improve CRT response multimodality imaging (especially echocardiography, computed tomography and cardiac magnetic resonance) could play a decisive role and extensive literature has been published on the matter. However, we are so far from routinary use in clinical practice. Electrocardiography (with respect to left ventricle capture and QRS narrowing) may represent a simple and low cost approach for early prediction of potential non-responder, with immediate practical implications. CONCLUSION: This brief review covers the current recommendations for CRT in HF patients with particular attention to the potential benefits of multimodality imaging and electrocardiography in improving response rate.

Aortic stenosis: insights on pathogenesis and clinical implications.

Aortic stenosis (AS) is a common valvular heart disease in the Western populations, with an estimated overall prevalence of 3% in adults over 75 years. To understand its patho-biological processes represents a priority. In elderly patients, AS usually involves trileaflet valves and is referred to as degenerative calcific processes. Scientific evidence suggests the involvement of an active "atherosclerosis-like" pathogenesis in the initiation phase of degenerative AS. To the contrary, the progression could be driven by different forces (such as mechanical stress, genetic factors and interaction between inflammation and calcification). The improved understanding presents potentially new therapeutic targets for preventing and inhibiting the development and progression of the disease. Furthermore, in clinical practice the management of AS patients implies the evaluation of generalized atherosclerotic manifestations (i.e., in the coronary and carotid arteries) even for prognostic reasons. In counselling elderly patients, the risk stratification should address individual frailty beyond the generic risk scores. In these regard, the co-morbidities, and in particular those linked to the global atherosclerotic burden, should be carefully investigated in order to define the risk/benefit ratio for invasive treatment strategies. We present a detailed overview of insights in pathogenesis of AS with possible practical implications.

Magnitude of QRS duration reduction after biventricular pacing identifies responders to cardiac resynchronization therapy.

BACKGROUND: Several studies have investigated the association between native QRS duration (QRSd) or QRS narrowing and response to biventricular pacing. However, their results have been conflicting. The aim of our study was to determine the association between the relative change in QRS narrowing index (QI) and clinical outcome and prognosis in patients who undergo cardiac resynchronization therapy (CRT) implantation. METHODS AND RESULTS: We included 311 patients in whom a CRT device was implanted in accordance with current guidelines for CRT. On implantation, the native QRS, the QRSd and the QI during CRT were measured. After 6months, 220 (71%) patients showed a 10% reduction in LVESV. The median [25th-75th] QI was 14.3% [7.2-21.4] and was significantly related to reverse remodeling (r=+0.22; 95%CI: 0.11-0.32, p=0.0001). The cut-off value of QI that best predicted LV reverse remodeling after 6months of CRT was 12.5% (sensitivity=63.6%, specificity=57.1%, area under the curve=0.633, p=0.0002). The time to the event death or cardiovascular hospitalization was significantly longer among patients with QI>12.5% (log-rank test, p=0.0155), with a hazard ratio (HR) of 0.3 [95%CI: 0.11-0.78]. In the multivariate regression model adjusted for baseline parameters, a 10% increment in QI (HR=0.61[0.44-0.83], p=0.002) remained significantly associated with CRT response. CONCLUSIONS: Patients with a larger decrease in QRSd after CRT initiation showed greater echocardiographic reverse remodeling and better outcome from death or cardiovascular hospitalization. QI is an easy-to-measure variable that could be used to predict CRT response at the time of pacing site selection or pacing configuration programming.

Coronary artery fistulas as a cause of angina: How to manage these patients?

Coronary artery fistulas represent the most common hemodynamically significant congenital defect of the coronary arteries and the clinical presentation is mainly dependent on the severity of the left-to-right shunt. We describe a case of a 55-year-old man with history of chest pain and without history of previous significant chest wall trauma or any invasive cardiac procedures. A coronary multislice computed tomography showed two large coronary fistulas arising from the left anterior descending coronary artery and ending in an angiomatous plexus draining into the common pulmonary trunk. Coronary angiography confirmed the CT finding and showed a third fistulous communication arising from the sinus node artery. Although coronary fistulas are infrequent, they are becoming increasingly important because their management and treatment could prevent serious complications. The latest guidelines of the American College of Cardiology/American Heart Association indicate as Class I recommendation the percutaneous or surgical closure for large fistulas regardless of symptoms. In this manuscript, we provide a detailed review of the literature on this topic, focusing on the clinical management of these patients.

Chronic Stress and Early Recurrence of Takotsubo Cardiomyopathy: A Clinical Case.

Takotsubo cardiomyopathy (TC) is characterized by transient systolic dysfunction of the apical and middle segments of the left ventricle, accompanied by electrocardiographic abnormalities and mild elevation of cardiac biomarker levels in the absence of obstructive coronary artery disease. The following case is of a woman suffering from chronic emotional stress with a very early recurrence. An acute trigger event was not detectable in both cases. It is possible to suppose that, in predisposed subjects, chronic stress by increasing sympathetic activity may be considered not only a trigger for TC, but also a negative prognostic factor for early recurrence.

Atherosclerosis, degenerative aortic stenosis and statins.

Aortic stenosis is the most common valvular heart disease among adult subjects in western countries The current treatment for aortic stenosis is aortic valve replacement. The possibility of a medical treatment that can slow the progression of aortic stenosis is very fascinating and statins have been tested to reduce the progression of degenerative aortic stenosis (DAS). The rationale for statin treatment in DAS has a deep pathophysiological substrate, in fact inflammation and lipid infiltration constitute the same histopathological pattern of both aortic stenosis and atherosclerosis and these two conditions have the same risk factors. Whether retrospective studies have shown some efficacy of statins in halting the progression of DAS, prospective trials have shown controversial results. A recently published large and randomized controlled trial SEAS found that statins have no significant effect on the progression of aortic stenosis, the ASTRONOMER, recently confirmed this data. The most plausible hypothesis is that coronary artery disease and DAS, have a common pathogenetic background and a distinct evolution due to different factors (mechanical stress, genetic factors, interaction between inflammatory cells and calcification mediators). Thus, treatment with statins is not recommended in patients with valvular aortic stenosis and without conventional indications to lipid-lowering treatment.