Extent of Late Gadolinium Enhancement Predicts Thromboembolic Events in Patients With Hypertrophic Cardiomyopathy.

BACKGROUND: Thromboembolic complications such as ischemic stroke or peripheral arterial thromboembolism are known complications in hypertrophic cardiomyopathy (HCM). We sought to assess the clinical and cardiovascular magnetic resonance (CMR) characteristics of patients with HCM suffering from thromboembolic events and analyzed the predictors of these unfavorable outcomes.Methods and Results:The 115 HCM patients underwent late gadolinium enhanced (LGE) CMR and were included in the study. Follow-up was 5.6±3.6 years. The primary endpoint was the occurrence of thromboembolic events (ischemic stroke or peripheral arterial thromboembolism). It occurred in 17 (14.8%) patients (event group, EG), of whom 64.7% (11) were men. During follow-up, 10 (8.7%) patients died. Patients in the EG showed more comorbidities, such as heart failure (EG 41.2% vs. NEG (non-event group) 14.3%, P<0.01) and atrial fibrillation (AF: EG 70.6% vs. NEG 36.7%, P<0.01). Left atrial end-diastolic volume was significantly higher in the EG (EG 73±24 vs. NEG 50±33 mL/m2, P<0.01). Both the presence and extent of LGE were enhanced in the EG (extent% EG 23±15% vs. NEG 8±9%, P<0.0001). No patient without LGE experienced a thromboembolic event. Multivariate analysis revealed AF and LGE extent as independent predictors. CONCLUSIONS: LGE extent (>14.4%) is an independent predictor for thromboembolic complications in patients with HCM and might therefore be considered as an important risk marker. The risk for thromboembolic events is significantly elevated if accompanied by AF.

Brugada syndrome: clinical presentation and genotype-correlation with magnetic resonance imaging parameters.

AIMS: The purpose of the this study was to evaluate a possible genotype-phenotype correlation in BrS patients and to analyze possible associations with clinical events in affected patients. SCN5A gene encodes the alpha-subunit of the voltage-gated sodium channel NaV1.5. Its mutations are associated with a broad spectrum of hereditary arrhythmias such as long-QT syndrome, cardiac conduction diseases, and Brugada syndrome (BrS). Experimental studies have shown an interaction between SCN5A and cellular cytoskeleton, explaining its functional role in cellular integrity of heart cells. METHODS AND RESULTS: Cardiovascular magnetic resonance was performed on 81 consecutive genetically screened BrS patients and 30 healthy controls. Left ventricular (LV) and right ventricular (RV) volumes and dimensions were assessed and compared with respect to the genotype. Brugada syndrome patients with an SCN5A mutation (16 patients; 20%) revealed significantly larger RV volumes, along with lower RV ejection fraction, than patients without a mutation or controls, indicating a more severe phenotype in patients with a mutation. Furthermore, patients with an SCN5A mutation showed significantly more often a spontaneous type 1 BrS-electrocardiogram (ECG). In multivariate analysis, the presence of a spontaneous type 1 BrS-ECG showed the strongest association with cardiac events. Receiver-operating characteristic curve analysis indicated good predictive performance of RV end-diastolic volume, RV end-systolic, and LV cardiac output (area under the curve = 0.81, 0.81, and 0.2), with respect to the presence of an SCN5A mutation. CONCLUSION: Brugada syndrome patients with an SCN5A mutation reveal distinct changes in RV volumes and function when compared with those without an SCN5A mutation. Furthermore, mutation-positive patients have a higher likelihood of a spontaneous type 1 BrS-ECG, which is associated with a higher incidence of clinical events. Cardiovascular magnetic resonance may provide additional insight to distinguish between SCN5A mutation-positive and -negative BrS patients.

Right Ventricular and Right Atrial Involvement Can Predict Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy?

OBJECTIVES AND BACKGROUND: Atrial fibrillation (AF) is associated with clinical deterioration, stroke and disability in patients with hypertrophic cardiomyopathy (HCM). Therefore, the objective of this study was to evaluated cardiac magnetic resonance (CMR)-derived determinants for the occurrence of AF in patients with HCM. METHODS: 98 Patients with HCM and 30 healthy controls underwent CMR and were followed-up for 6 ± 3 years. RESULTS: 19 (19.4%) patients presented with AF at initial diagnosis, 19 (19.4%) developed AF during follow-up and 60 (61.2%) remained in sinus rhythm (SR). Compared to healthy controls, patients with HCM who remained in SR presented with significantly increased left ventricular mass, an elevated left ventricular remodeling index, enlarged left atrial volumes and reduced septal mitral annular plane systolic excursion (MAPSE) compared to healthy controls. Whereas HCM patients who presented with AF at initial diagnosis and those who developed AF during follow-up additionally presented with reduced tricuspid annular plane systolic excursion (TAPSE) and right atrial (RA) dilatation. Receiver-operator curve analysis indicated good predictive performance of TAPSE, RA diameter and septal MAPSE (AUC 0.73, 0.69 and 0.71, respectively) to detect patients at risk of developing AF. CONCLUSION: Reduced MAPSE measurements and enlarged LA volumes seems to be a common feature in patients with HCM, whereas reduced TAPSE and RA dilatation only seem to be altered in patients with history of AF and those developing AF. Therefore, they could serve as easy determinable markers of AF in patients with HCM.

Comparison of electrical velocimetry and cardiac magnetic resonance imaging for the non-invasive determination of cardiac output.

A novel algorithm of impedance cardiography referred to as electrical velocimetry (EV) has been introduced for non-invasive determination of cardiac output (CO). Previous validation studies yielded diverging results and no comparison with the non-invasive gold standard cardiac magnetic resonance imaging (CMR) has been performed. We therefore aimed to prospectively assess the accuracy and reproducibility of EV compared to CMR. 152 consecutive stable patients undergoing CMR were enrolled. EV measurements were taken twice before or after CMR in supine position and averaged over 20 s (AESCULON(®), Osypka Medical, Berlin, Germany). Bland-Altman analysis showed insufficient agreement of EV and CMR with a mean bias of 1.2 ± 1.4 l/min (bias 23 ± 26 %, percentage error 51 %). Reproducibility was high with 0.0 ± 0.3 l/min (bias 0 ± 8 %, percentage error 15 %). Outlier analysis revealed gender, height, CO and stroke volume (SV) by CMR as independent predictors for larger variation. Stratification of COCMR in quintiles demonstrated a good agreement for low values (<4.4 l/min) with bias increasing significantly with quintile as high as 3.1 ± 1.1 l/min (p < 0.001). Reproducibility was not affected (p = 0.71). Subgroup analysis in patients with arrhythmias (p = 0.19), changes in thoracic fluid content (p = 0.51) or left heart failure (p = 0.47) could not detect significant differences in accuracy. EV showed insufficient agreement with CMR and good reproducibility. Gender, height and increasing CO and SV were associated with increased bias while not affecting reproducibility. Therefore, absolute values should not be used interchangeably in clinical routine. EV yet may find its place for clinical application with further investigation on its trending ability pending.

Is arterial pulse contour analysis using Nexfin a new option in the noninvasive measurement of cardiac output?--A pilot study.

OBJECTIVES: A growing interest in monitoring cardiac output (CO) noninvasively has emerged; however, its determination has been difficult using the standard approaches. The aim of this study was to evaluate the accuracy and precision of pulse contour analysis (PCA) compared with cardiac magnetic resonance imaging (CMR). DESIGN: A single-center prospective study. SETTING: A university hospital. PARTICIPANTS: Thirty-nine consecutive stable patients undergoing CMR. INTERVENTIONS: CO was determined twice by PCA using the Nexfin monitoring system (BMEYE BV, Amsterdam, The Netherlands). Measurements were performed after 10 minutes of rest in a stable supine position immediately before or after the CMR examination. MEASUREMENTS AND MAIN RESULTS: There was a mean bias of 0.2 ± 1.9 L/min between CMR and PCA and a reproducibility of 0.2 ± 0.6 L/min for PCA. Between 4.8 and 6.3 L/min (second quartile of COCMR), there was a good agreement (mean bias = -0.2 ± 1.3 L/min). Comparing quartile 1 (-1.3 ± 2.0 L/min) overestimating and quartiles 3 (1.4 ± 0.9 L/min) and 4 (0.9 ± 2.0 L/min) underestimating CO, a statistically significant difference was found. The reproducibility was not affected by the quartile (p = 0.23, analysis of variance), whereas there was a significant difference between the nonoutlier and outlier group when using the Mann-Whitney U test (p = 0.02). CONCLUSIONS: Noninvasive PCA allows the safe and economic measurement of CO, yet it still has major limitations. Although the agreement with CMR was acceptable, there was a clinically unacceptable variation; absolute values should not be used interchangeably. These results suggest that therapeutic interventions and clinical decisions should not be based on noninvasive PCA measurements at the present time.

Impact of functional, morphological and clinical parameters on epicardial adipose tissue in patients with coronary artery disease.

BACKGROUND: Because a close relationship between epicardial adipose tissue (EAT) and coronary artery disease (CAD) has been shown, the impact of functional, morphological and clinical parameters to identify potential determinants of EAT was investigated. METHODS AND RESULTS: Clinical and cardiac magnetic resonance parameters were determined and correlated to the amount of EAT in 158 patients with CAD and 40 healthy subjects. Patients with CAD and left ventricular function (LVEF) ≥50% revealed significantly elevated EAT (36±11g/m²) compared to healthy controls (31±8g/m²) and to patients with LVEF <50% (26±8.0g/m²). In the whole study population, only LVEF (P=0.003), body mass index (BMI) (P=0.004) and left ventricular end diastolic diameter (LV-EDD) (P=0.004) remained significantly associated with EAT after multivariate analysis. Subgroup analysis in patients with CAD and LVEF ≥50% showed that BMI (P=0.03) was the only correlate of EAT. However, in patients with CAD and LVEF <50%, indexed LV end diastolic mass (LV-EDMI) (P=0.003) and the extent of late gadolinium enhancement (LGE %) (P=0.03) remained significantly correlated with EAT in multivariate analysis. CONCLUSIONS: The amount and the determinants of EAT differ according to the LVEF in patients with CAD. Thus, different amounts of EAT reflect different stages of CAD underlining the complex interaction of EAT in the pathogenesis and progression of ischemic cardiomyopathy.

Predictors of electrical storm recurrences in patients with implantable cardioverter-defibrillators.

AIMS: To determine prevalence and predictors of electrical storm recurrences (ES-Rs) in patients with implantable cardioverter-defibrillators (ICDs) as electrical storms (ESs) represent serious clinical events carrying a high risk of mortality. METHODS AND RESULTS: Single-centre study analysing data of consecutive patients receiving an ICD between 1993 and 2008. Electrical storm was defined as ≥ 3 separate ventricular tachyarrhythmic (VT/VF) episodes ≤ 24 h. Nine hundred and fifty-five patients [mean left ventricular ejection fraction (LVEF) 35.7 ± 15.6%] were prospectively followed for 54.2 ± 35.5 months. In 274 of 955 patients (28.7%), 2871 VT/VF episodes were observed. One hundred and fifty-three ES episodes occurred in 63 of 955 patients (6.6%). Thirty-two of 63 patients (50.8%) experienced ≥ 2 ES episodes. Twenty-six of 32 patients (81.2%) with ES-Rs experienced the second ES episode within 1 year after the initial event. Cox regression analysis identified an LVEF ≤ 30% (OR 2.2; 95% CI 1.021-4.856; P = 0.044) and a patient's age >65 years (OR 3.5; 95% CI 1.207-10.176; P = 0.021) to be predictive for ES-Rs. Patients with angiotensin-converting enzyme (ACE) inhibitor therapy were less likely to experience ES-Rs (OR 0.39; 95% CI 0.187-0.817; P = 0.013). CONCLUSIONS: Electrical storm events are not rare in a 'real-world' patient population with ICDs (6.6% in 4.5 years). The risk for ES-Rs, especially within the first year after the initial event, is high. Left ventricular ejection fraction ≤ 30%, age >65 years, and a lack of ACE inhibitor therapy are independent predictors of ES-R.

Determinants of arterial stiffness in patients with atrial fibrillation.

BACKGROUND: Arterial stiffness has emerged as a strong predictor of cardiovascular disease, end-organ damage and all-cause mortality. Although increased arterial stiffness has been described as a predictor of atrial fibrillation, the relationship between arterial stiffness and atrial fibrillation is uncertain. AIM: We assessed arterial stiffness in patients with atrial fibrillation compared with that in a control group. METHODS: We enrolled 151 patients with atrial fibrillation who underwent pulmonary vein isolation (mean age 71.1±9.8 years) and 54 control patients with similar cardiovascular risk profiles and sinus rhythm, matched for age (mean age 68.6±15.7 years) and sex. Aortic distensibility as a measure of arterial stiffness was assessed by transoesophageal echocardiography. Patients with atrial fibrillation were followed over a median of 21 (15 to 31) months. RESULTS: Compared with control patients, patients with atrial fibrillation had significantly lower aortic distensibility (1.8±1.1 vs. 2.1±1.1 10-3mmHg-1; P=0.02). Age (hazard ratio 0.67, 95% confidence interval 0.003 to 0.03; P=0.02) and pulse pressure (hazard ratio -1.35, 95% confidence interval -0.07 to -0.03; P<0.0001) were the strongest predictors of decreased aortic distensibility in the study cohort. This effect was independent of the type of atrial fibrillation (paroxysmal/persistent). During follow-up, decreased aortic distensibility was a predictor of cardiovascular and all-cause hospitalizations, as well as recurrences of atrial fibrillation, with a higher incidence rate of events in patients in the lowest aortic distensibility quartile (P=0.001). CONCLUSIONS: Aortic distensibility was significantly reduced in patients with atrial fibrillation, with age and pulse pressure showing the strongest correlation, independent of the type of atrial fibrillation. Additionally, decreased aortic distensibility was associated with cardiovascular and all-cause hospitalizations, as well as recurrences of atrial fibrillation, which showed a quartile-dependent occurrence.

High resolution myocardial magnetic resonance stress perfusion imaging at 3 T using a 1 M contrast agent.

OBJECTIVE: Stress perfusion magnetic resonance imaging (MSPMRI) is an established technique for the assessment of myocardial perfusion. Shortcomings at 1.5 T are low signal to noise ratio (SNR) and contrast to noise ratio (CNR). One approach to overcome these shortcomings is to increase field strength and contrast concentration. The aim of our study was to investigate the diagnostic capability of high resolution MSPMRI at 3-T field strength using a 1 M contrast agent. MATERIAL AND METHODS: Fifty-seven patients (62.3 +/- 11.0 years) with symptoms of coronary artery disease (CAD) were examined at 3 T. MMRSPI was assessed using a 2D saturation recovery gradient echo (SR GRE) sequence in short axis orientation (TR 1.9 ms, TE 1.0 ms, flip 12 degrees , 0.1 mmol gadobutrol/kg body weight (bw), 140 microg adenosine/kg bw/min). Perfusion images were assessed visually and semiquantitatively (upslope, peak signal intensity (SI), and myocardial perfusion reserve index (MPRI)). Standard of reference was invasive coronary angiography. RESULTS: Stress-induced hypoperfusion was found in 43 patients. Sensitivity for hemodynamically relevant CAD (stenoses greater than 70%) was 95%/98%, specificity 80%/87%, diagnostic accuracy 91%/95% (reader 1/reader 2). The MPRI was significantly lower in hypoperfused myocardium (1.3 +/- 0.2) compared with normal myocardium (2.6 +/- 0.7). CONCLUSION: High resolution MMRSPI at 3 T using 1 M contrast agent under daily routine conditions provides reliable detection of stress-induced myocardial hypoperfusion with higher diagnostic accuracy than 1.5-T conditions.

Epicardial adipose tissue in patients with heart failure.

PURPOSE: The aim of this study was to evaluate the extent of epicardial adipose tissue (EAT) and its relationship with left ventricular (LV) parameters assessed by cardiovascular magnetic resonance (CMR) in patients with congestive heart failure (CHF) and healthy controls. BACKGROUND: EAT is the true visceral fat deposited around the heart which generates various bioactive molecules. Previous studies found that EAT is related to left ventricular mass (LVM) in healthy subjects. Further studies showed a constant EAT to myocardial mass ratio in normal, ischemic and hypertrophied hearts. METHODS: CMR was performed in 66 patients with CHF due to ischemic cardiomyopathy (ICM), or dilated cardiomyopathy (DCM) and 32 healthy controls. Ventricular volumes, dimensions and LV function were assessed. The amount of EAT was determined volumetrically and expressed as mass indexed to body surface area. Additionally, the EAT/LVM and the EAT/left ventricular remodelling index (LVRI) ratios were calculated. RESULTS: Patients with CHF had less indexed EAT mass than controls (22 +/- 5 g/m2 versus 34 +/- 4 g/m2, p < 0.0001). In the subgroup analysis there were no significant differences in indexed EAT mass between patients with ICM and DCM (21 +/- 4 g/m2 versus 23 +/- 6 g/m2, p = 0.14). Linear regression analysis showed that with increasing LV end-diastolic diameter (LV-EDD) (r = 0.42, p = 0.0004) and LV end-diastolic mass (LV-EDM) (r = 0.59, p < 0.0001), there was a significantly increased amount of EAT in patients with CHF. However, the ratio of EAT mass/LV-EDM was significantly reduced in patients with CHF compared to healthy controls (0.54 +/- 0.1 versus 0.21 +/- 0.1, p < 0.0001). In CHF patients higher indexed EAT/LVRI-ratios in CHF patients correlated best with a reduced LV-EF (r = 0.49, p < 0.0001). CONCLUSION: Patients with CHF revealed significantly reduced amounts of EAT. An increase in LVM is significantly related to an increase in EAT in both patients with CHF and controls. However, different from previous reports the EAT/LVEDM-ratio in patients with CHF was significantly reduced compared to healthy controls. Furthermore, the LV function correlated best with the indexed EAT/LVRI ratio in CHF patients. Metabolic abnormalities and/or anatomic alterations due to disturbed cardiac function and geometry seem to play a key role and are a possible explanation for these findings.

Extent of late gadolinium enhancement detected by cardiovascular magnetic resonance correlates with the inducibility of ventricular tachyarrhythmia in hypertrophic cardiomyopathy.

BACKGROUND: Myocardial fibrosis is frequently identified in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to investigate the role of myocardial fibrosis detected by late gadolinium-enhancement (LGE) cardiovascular magnetic resonance (CMR) as a potential arrhythmogenic substrate in HCM. We hypothesized that the extent of LGE might be associated with the inducibility of ventricular tachyarrhythmias (VT) during programmed ventricular stimulation (PVS). METHODS: We evaluated retrospectively LGE CMR of 76 consecutive HCM patients, of which 43 presented with one or more risk factors for sudden cardiac death (SCD) and were therefore clinically classified as high-risk patients. Of these 43 patients, 38 additionally underwent an electrophysiological testing (EP). CMR indices and the extent of LGE, given as the % of LV mass with LGE were correlated with the presence of risk factors for SCD and the results of EP. RESULTS: High-risk patients had a significant higher prevalence of LGE than low-risk patients (29/43 [67%] versus 14/33 [47%]; p = 0.03). Also the % of LV mass with LGE was significantly higher in high-risk patients than in low-risk patients (14% versus 3%, p = 0.001, respectively). Of the 38 high- risk patients, 12 had inducible VT during EP. LV function, volumes and mass were comparable in patients with and without inducible VT. However, the % of LV mass with LGE was significantly higher in patients with inducible VT compared to those without (22% versus 10%, p = 0.03). The prevalence of LGE was, however, comparable between HCM patients with and those without inducible VT (10/12 [83%] versus 15/26 [58%]; p = 0.12). In the univariate analysis the % of LV mass with LGE and the septal wall thickness were significantly associated with the high-risk group (p = 0.001 and 0.004, respectively). Multivariate analysis demonstrated that the extent of LGE was the only independent predictor of the risk group (p = 0.03). CONCLUSIONS: The extent of LGE in HCM patients correlated with risk factors of SCD and the likelihood of inducible VT. Furthermore, LGE extent was the only independent predictor of the risk group. This supports the hypothesis that the extent of fibrosis may serve as potential arrhythmogenic substrate for the occurrence of VT, especially in patients with clinical risk factors for SCD.

The impact of pulmonary disease on noninvasive measurement of cardiac output by the inert gas rebreathing method.

Cardiac output (CO) is an important parameter for diagnosis and therapy of heart diseases, but it is still difficult to determine. Innocor, a novel noninvasive inert gas rebreathing (IGR) system, has shown promising results. However, the impact of pulmonary diseases on IGR remains unclear. The aim of the study therefore was to assess the accuracy and reliability of IGR in patients with distinct chronic lung disease. A total of 96 patients were enrolled, including 48 consecutive patients with variant lung diseases (group A) and 48 pair-matched pulmonary healthy patients (group B). CO was measured with cardiac magnetic resonance imaging (CMR) and IGR. Lung function testing was done by spirometry [FEV(1)/FVC (forced expiratory volume in one second/forced vital capacity), VC (vital capacity)] and determination of the diffusing capacity of the lung for carbon monoxide divided by alveolar volume (DLCO/VA). In group A we found a mean CO of 4.7 ± 1.3 L/min by IGR and 4.9 ± 1.2 L/min by CMR. Group B showed a mean CO of 4.8 ± 1.4 L/min by IGR and 5.0 ± 1.3 L/min by CMR. Bland-Altman analysis revealed good correspondence between CMR and IGR, with an average deviation of 0.1 ± 1.0 L/min in group A and 0.1 ± 1.0 L/min in group B (p = 0.99). Multiple regression analysis for the pulmonary parameters did not show a statistically significant impact on the mean bias of CO measurements (FEV(1)/FVC: r = 0.01, p = 0.91; VC: r = -0.2, p = 0.13; and DLCO/VA: r = 0.04, p = 0.82). IGR allows a feasible determination of CO even in patients with lung diseases. The accuracy of the IGR method is not influenced by either pulmonary obstructive and restrictive diseases or a reduced DLCO.

Recurrence of Atrial Fibrillation in Dependence of Left Atrial Volume Index.

BACKGROUND/AIM: Despite advances in the treatment strategies of patients with atrial fibrillation (AF), the risk of AF recurrences is still over 50%. An increased left atrial volume index (LAVI) reflects left ventricular diastolic dysfunction (DD) and deterioration of the LA function. This study aims to determine AF recurrence following cardioversion (CV) or catheter ablation for AF (pulmonary vein isolation; PVI) in dependence of DD and LAVI. PATIENTS AND METHODS: One hundred and sixty-two patients with paroxysmal or persistent AF in whom either CV or PVI were performed were included and followed over a mean of 22.9±3.8 months. Recurrence was defined as any recurrence of AF that occurred 3 months following the procedure. DD and LAVI were assessed using transthoracic echocardiography (TTE). RESULTS: Recurrent AF occurred in 100 (61.7%) patients, predominantly following CV [CV 41 (76.2%) vs. PVI 59 (54.6%), p<0.0001]. Both DD and an increased LAVI were more common in the recurrence-group [DD 46.0% vs. 14.5%, p=0.0001; LAVI (ml/m2) 49.0±18.6 vs. 26.3±7.0, p<0.0001]. ROC analysis revealed LAVI>36 ml/m2 as cut-off (p<0.0001, AUC=0.92, 95%CI=0.87-0.97, sensitivity=76%, specificity=94%). In the multivariate analysis, DD (HR=1.6, 95%CI=1.3-2.1, p=0.04) and LA enlargement (defined as LAVI>36 ml/m2 with HR=2.1, 95%CI=1.8-2.7, p<0.0001) could be identified as independent predictors of AF recurrence after attempting to control the heart rhythm. CONCLUSION: LA enlargement and DD are independent risk factors associated with AF recurrence after initial successful rhythm control attempt. These findings have implications for timing of either ablation or CV.

Arterial Stiffness Is Associated With Increased Symptom Burden in Patients With Atrial Fibrillation.

BACKGROUND: Increased arterial stiffness (AS) has been described as a predictor of atrial fibrillation (AF). This study was performed to assess whether increased AS leads to a higher symptom burden in patients with AF. METHODS: One hundred sixty-two consecutive patients (104 male, 58 female) with diagnosed AF (paroxysmal or persistent) were enrolled. Symptoms most likely attributable to AF were quantified according to the Canadian Cardiovascular Society Severity of Atrial Fibrillation (SAF) scale. AS indices (aortic distensibility, cyclic circumferential strain, and aortic compliance) were characterized using transoesophageal echocardiography. RESULTS: The cohort was divided into asymptomatic to oligosymptomatic (SAF scale 0-1, n = 78 [48.1%]) and symptomatic (SAF scale ≥ 2, n = 84 [51.9%]) patients. Symptomatic patients tended to be younger (median, 75 [interquartile range (IQR) 67-80] vs 71 [65-79]; P = 0.047) and were more likely to be female (22 [28.2%] vs 36 [42.9%]; P = 0.052). Hypertension was more frequent in symptomatic patients. Aortic compliance indices each were reduced in symptomatic patients, most pronounced for aortic compliance (median, 0.05 [IQR 0.03-0.06] vs 0.04 [0.03-0.05] cm/mm Hg; P = 0.01) followed by cyclic circumferential strain (median, 0.09 [IQR 0.07-0.11] vs 0.07 [0.04-0.10]; P = 0.02) and aortic distensibility (10-3 mm Hg-1, median, 1.74 [IQR 1.34-2.24] vs 1.54 [1.12-2.08]; P = 0.03). Multivariable analysis revealed aortic compliance as an independent predictor for symptoms in patients with AF with an odds ratio of 2.6 (95% confidence interval, 1.2-3.4; P = 0.003). CONCLUSIONS: AS contributes to a high symptom burden in patients with AF, emphasizing the prognostic role of AS in the early detection and prevention in patients with AF.

Perception of atrial fibrillation in dependence of neuroticism.

OBJECTIVE: Atrial fibrillation (AF) is associated with a varying symptom burden, which ranges from completely unawareness to disabling conditions. The present cross-sectional study tried to assess if neuroticism is associated with a greater degree of perception of AF related symptoms. METHODS: 162 patients who were considered for catheter ablation of AF were included. AF related symptom burden was quantified according to the European Heart Rhythm Association (EHRA) score. Personality traits were assessed using the Big Five personality traits (5BT). RESULTS: Female patients reported higher symptom burden. Higher EHRA scores were furthermore associated with treatment with antiarrhythmic agents, digitalis, direct oral anticoagulants (DOAC), and antidepressant treatment, as well as suffering from heart failure or chronic kidney disease. Neuroticism showed a positive correlation to AF related symptom burden with significantly higher neuroticism scores in patients with higher EHRA scores (Rho = 0.41; 95%CI 0.26 to 0.53; p < .001), while no association was demonstrated for the other four personality traits. Multiple linear regression analysis revealed neuroticism as strongest independent predictor for symptomatic AF, followed by treatment with antiarrhythmic agents and DOAC. CONCLUSIONS: Perception of AF related symptoms is a multifactorial process, which in our cohort was independently associated with neuroticism. Patients with higher symptom burden were also more likely to receive antiarrhythmic agents and DOAC, as well as antidepressants. TRIAL REGISTRATION: German registry for clinical studies (DRKS), DRKS00019007.

CMR findings in patients with hypertrophic cardiomyopathy and atrial fibrillation.

OBJECTIVES: We sought to evaluate the relation between atrial fibrillation (AF) and the extent of myocardial scarring together with left ventricular (LV) and atrial parameters assessed by late gadolinium-enhancement (LGE) cardiovascular magnetic resonance (CMR) in patients with hypertrophic cardiomyopathy (HCM). BACKGROUND: AF is the most common arrhythmia in HCM. Myocardial scarring is also identified frequently in HCM. However, the impact of myocardial scarring assessed by LGE CMR on the presence of AF has not been evaluated yet. METHODS: 87 HCM patients underwent LGE CMR, echocardiography and regular ECG recordings. LV function, volumes, myocardial thickness, left atrial (LA) volume and the extent of LGE, were assessed using CMR and correlated to AF. Additionally, the presence of diastolic dysfunction and mitral regurgitation were obtained by echocardiography and also correlated to AF. RESULTS: Episodes of AF were documented in 37 patients (42%). Indexed LV volumes and mass were comparable between HCM patients with and without AF. However, indexed LA volume was significantly higher in HCM patients with AF than in HCM patients without AF (68 +/- 24 ml.m-2 versus 46 +/- 18 ml.m-2, p = 0.0002, respectively). The mean extent of LGE was higher in HCM patients with AF than those without AF (12.4 +/- 14.5% versus 6.0 +/- 8.6%, p = 0.02). When adjusting for age, gender and LV mass, LGE and indexed LA volume significantly correlated to AF (r = 0.34, p = 0.02 and r = 0.42, p < 0.001 respectively). By echocardiographic examination, LV diastolic dysfunction was evident in 35 (40%) patients. Mitral regurgitation greater than II was observed in 12 patients (14%). Multivariate analysis demonstrated that LA volume and presence of diastolic dysfunction were the only independent determinant of AF in HCM patients (p = 0.006, p = 0.01 respectively). Receiver operating characteristic curve analysis indicated good predictive performance of LA volume and LGE (AUC = 0.74 and 0.64 respectively) with respect to AF. CONCLUSION: HCM patients with AF display significantly more LGE than HCM patients without AF. However, the extent of LGE is inferior to the LA size for predicting AF prevalence. LA dilation is the strongest determinant of AF in HCM patients, and is related to the extent of LGE in the LV, irrespective of LV mass.

Non-invasive measurement of hemodynamic response to postural stress using inert gas rebreathing.

In postural stress, an increased preload volume leads to higher stroke volume (SV) according to the Frank-Starling law of the heart. The present study aimed to evaluate the hemodynamic response to postural stress using non-invasive inert gas rebreathing (IGR) in patients with normal as well as impaired left ventricular function. Hemodynamic measurements were performed in 91 patients undergoing cardiac magnetic resonance imaging (CMR). Mean cardiac output and SV determined by IGR were 4.4±1.3 l/min and 60±19 ml in the upright position, which increased significantly to 5.0±1.2 l/min and 75±23 ml in the supine position (P<0.01). Left ventricular systolic function was normal [ejection fraction (EF) ≥55%] in 42 patients as determined by CMR. In 21 patients, EF was mildly abnormal (45-54%), in 16 patients moderately abnormal (30-44%) and in 12 patients severely abnormal (<30%). An overall trend for a lower percentage change in SV (%ΔSV) was indicated with increasing impairment of ejection fraction. In patients with abnormal EF in comparison to those with normal EF, the %ΔSV was significantly lower (13% vs. 22%; P=0.03). Non-invasive measurement of cardiac function using IGR during postural changes may be feasible and detected significant difference in %ΔSV in patients with normal and impaired EF according to the Frank-Starling law of the heart. Several clinical scenarios including cases of heart rhythm disturbances or pulmonary or congenital heart disease are worthy of further investigation.

Comparison of peri and post-procedural complications in patients undergoing revascularisation of coronary artery multivessel disease by coronary artery bypass grafting or protected percutaneous coronary intervention with the Impella 2.5 device.

BACKGROUND: While coronary artery bypass grafting remains the standard treatment of complex multivessel coronary artery disease, the advent of peripheral ventricular assist devices has enhanced the safety of percutaneous coronary intervention. We therefore evaluated the safety in terms of inhospital outcome comparing protected high-risk percutaneous coronary intervention with the Impella 2.5 device and coronary artery bypass grafting in patients with complex multivessel coronary artery disease. METHODS: This retrospective study included patients with complex multivessel coronary artery disease (SYNTAX score >22) undergoing either coronary artery bypass grafting before the implementation of a protected percutaneous coronary intervention programme with a peripheral ventricular assist device or protected percutaneous coronary intervention with the Impella 2.5 device following the start of the programme. The primary endpoint consisted of inhospital major adverse cardiac and cerebrovascular events. The combined secondary endpoint included peri and post-procedural adverse events. RESULTS: A total of 54 patients (mean age 70.1±9.9 years, 92.6% men) were enrolled in the study with a mean SYNTAX score of 34.5±9.8. Twenty-six (48.1%) patients underwent protected percutaneous coronary intervention while 28 (51.9%) patients received coronary artery bypass grafting. The major adverse cardiac and cerebrovascular event rate was numerically higher in the coronary artery bypass grafting group (17.9 vs. 7.7%; P=0.43) but was not statistically significant. The combined secondary endpoint was not different between the groups; however, patients undergoing coronary artery bypass grafting experienced significantly more peri-procedural adverse events (28.6 vs. 3.8%; P<0.05). CONCLUSION: Patients with complex multivessel coronary artery disease undergoing protected percutaneous coronary intervention with the Impella 2.5 device experience similar intrahospital major adverse cardiac and cerebrovascular event rates when compared to coronary artery bypass grafting. Protected percutaneous coronary intervention represents a safe alternative to coronary artery bypass grafting in terms of inhospital adverse events.

Radiation Dose Levels of Retrospectively ECG-Gated Coronary CT Angiography Using 70-kVp Tube Voltage in Patients with High or Irregular Heart Rates.

RATIONALE AND OBJECTIVES: Despite ongoing technical refinements, coronary computed tomography angiography (cCTA) remains challenging in its diagnostic value by electrocardiographic (ECG) misregistration and motion artifacts, which commonly occur in patients with atrial fibrillation and high or irregular heart rates. The aim of this study was to evaluate the radiation dose and the number of inconclusive coronary segments at cCTA using retrospective ECG gating at 100 and 70 kV. MATERIALS AND METHODS: With institutional review board approval, 154 patients (median age 54 years, 98 men) with high or irregular heart rate prospectively underwent retrospectively ECG-gated cCTA without tube current modulation on a third-generation dual-source computed tomography (DSCT) system at 70 kV (n = 103) or on a second-generation DSCT system at 100 kV (n = 51). Images were reconstructed in best diastolic phase (BDP), best systolic phase (BSP), and in all phases (APs) at 10% intervals across the R-R cycle. Objective and subjective image qualities were evaluated as well as the presence of motion artifacts with the three different reconstruction approaches. RESULTS: The mean heart rate was 93 ± 16 bpm. The mean effective radiation dose was 4.5 mSv for 70 kV compared to 8.4 mSv for 100 kV (P < 0.05). At BDP reconstruction, 71% (n = 110) of the patients showed motion artifacts in one or more coronary segments. At BSP reconstruction, the number of patients with motion artifacts decreased to 37% (n = 57). In contrast, if images were reconstructed with the AP approach, all vessels and coronary segments were evaluable with both cCTA protocols. CONCLUSIONS: Retrospectively ECG-gated cCTA at 70 kV results in 52% decreased radiation dose. Further using the AP algorithm allowed for diagnostic evaluation of all coronary segments for stenosis, in contrast to BDP or BSP phase alone.

Incremental benefit of late gadolinium cardiac magnetic resonance imaging for risk stratification in patients with hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) has a low risk for sudden cardiac death (SCD). The ESC clinical risk prediction model estimates the risk of SCD using clinical and echocardiographical parameters without taking into account cardiac magnetic resonance (CMR) parameters. Therefore, we compared the CMR characteristics of 149 patients with low, intermediate and high ESC risk scores. In these patients left and right ventricular ejection fraction and volumes were comparable. Patients with a high ESC risk score revealed a significantly higher extent of late gadolinium enhancement (LGE) compared to patients with intermediate or a low risk scores. During follow-up of 4 years an extent of LGE ≥20% identified patients at a higher risk for major adverse cardiac arrhythmic events in the low and intermediate ESC risk group whereas an extent of LGE <20% was associated with a low risk of major adverse cardiac arrhythmic events despite a high ESC risk score ≥6%. Hence, we hypothesize that the extent of fibrosis might be an additional risk marker.