Diagnosis of ischemia in hypertrophic cardiomyopathy: role of computed tomography and nuclear stress testing.

PURPOSE OF REVIEW: Chest pain and myocardial ischemia are common features in patients with hypertrophic cardiomyopathy (HCM). This review addresses diagnostic roles of computed tomography and nuclear stress testing (NST) in patients with HCM. RECENT FINDINGS: Current evidence showed the limitation of NST in the diagnosis of epicardial coronary artery stenosis due to the prevalent microvascular dysfunction. In this context, the excellent negative predictive value of coronary computed tomography angiography (CCTA) makes it very attractive to serve as a gatekeeper to invasive angiography in low-risk symptomatic patients, either as the first noninvasive imaging test of choice or after the presence of perfusion defect seen in NST. Furthermore, the identification of coronary atherosclerosis process in the absence of obstructive lesion could have impacts on the management of risk factors for coronary artery disease. We also propose an algorithm for evaluation of ischemia in HCM patients based on the recent evidence. SUMMARY: In low-intermediate-risk symptomatic patients with HCM, both NST and CCTA are acceptable diagnostic tools for the evaluation of myocardial ischemia. In the presence of nuclear perfusion defect, CCTA can be used to rule out significant epicardial stenosis. Presence of significant major epicardial artery stenosis on CCTA or high-risk patients could be considered for invasive angiography.

A deep patient-similarity learning framework for the assessment of diastolic dysfunction in elderly patients.

AIMS: Age-related changes in cardiac structure and function are well recognized and make the clinical determination of abnormal left ventricular (LV) diastolic dysfunction (LVDD) particularly challenging in the elderly. We investigated whether a deep neural network (DeepNN) model of LVDD, previously validated in a younger cohort, can be implemented in an older population to predict incident heart failure (HF). METHODS AND RESULTS: A previously developed DeepNN was tested on 5596 older participants (66-90 years; 57% female; 20% Black) from the Atherosclerosis Risk in Communities Study. The association of DeepNN predictions with HF or all-cause death for the American College of Cardiology Foundation/American Heart Association Stage A/B (n = 4054) and Stage C/D (n = 1542) subgroups was assessed. The DeepNN-predicted high-risk compared with the low-risk phenogroup demonstrated an increased incidence of HF and death for both Stage A/B and Stage C/D (log-rank P < 0.0001 for all). In multi-variable analyses, the high-risk phenogroup remained an independent predictor of HF and death in both Stages A/B {adjusted hazard ratio [95% confidence interval (CI)] 6.52 [4.20-10.13] and 2.21 [1.68-2.91], both P < 0.0001} and Stage C/D [6.51 (4.06-10.44) and 1.03 (1.00-1.06), both P < 0.0001], respectively. In addition, DeepNN showed incremental value over the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI) guidelines [net re-classification index, 0.5 (CI 0.4-0.6), P < 0.001; C-statistic improvement, DeepNN (0.76) vs. ASE/EACVI (0.70), P < 0.001] overall and maintained across stage groups. CONCLUSION: Despite training with a younger cohort, a deep patient-similarity-based learning framework for assessing LVDD provides a robust prediction of all-cause death and incident HF for older patients.

Functional assessment of donor and recipient left atrium in heart transplant patients using full-volume three-dimensional echocardiography.

BACKGROUND: Atrial function plays an important role in many cardiac conditions, how recipient and donor compartments of left atrium (LA) of transplanted hearts differentially contribute to overall LA function in transplanted hearts has not been described. We tested whether three-dimensional transthoracic echocardiography (3DE) could be used to calculate these compartment-specific atrial functions. METHODS AND RESULTS: We analyzed 3DE images of 22 consecutive transplant patients who had diagnostic imaging quality (ages 59 ± 16 years) using TomTec Research Arena. The contour of the recipient and total LA were traced frame by frame, and the donor LA volume was calculated as the difference of the total LA volume minus the recipient LA volume. The LA ejection fractions of total LA, donor LA, and recipient LA were also calculated as (LA atrial end-diastolic volume - LA atrial end-systolic volume)/LA atrial end-diastolic volume of each compartment. Interobserver variability of LA volumes for the total, recipient, and donor compartments were 5.6 ± 2.4, 5.4 ± 2.0, and 9.3 ± 3.2 mL, respectively (n = 11). The donor LA ejection fraction was higher than that of recipient (41 ± 18% vs. 30 ± 14%, P = 0.013). When the patients were categorized as asymptomatic (New York Heart Association functional class [NYHA] functional class I) and symptomatic (NYHA functional class II-III), indexed donor LA atrial end-diastolic volume was significantly lower in asymptomatic patients as compared with symptomatic patients. CONCLUSIONS: Compartment-specific LA volumes can be calculated in orthotopic heart transplant patients using full-volume 3DE. Our findings may suggest that unique contribution of each LA compartment of transplanted hearts toward the symptoms of these patients.

Use of Computed Tomography Coronary Calcium Score for Coronary Artery Disease Risk Stratification During Liver Transplant Evaluation.

Background: End-stage liver disease (ESLD) is not considered a risk factor for atherosclerotic cardiovascular disease (ASCVD). However, lifestyle characteristics commonly associated with increased ASCVD risk are highly prevalent in ESLD. Emerging literature shows a high burden of asymptomatic coronary artery disease (CAD) in patients with ESLD and a high ASCVD risk in liver transplantation (LT) recipients. Coronary artery calcium score (CAC) is a noninvasive test providing reliable CAD risk stratification. We implemented an LT evaluation protocol with CAC playing a central role in triaging and determining the need for further CAD assessment. Here, we inform our results from this early experience. Methods: Patients with ESLD referred for LT evaluation were prospectively studied. We compared accuracy of CAC against that of CAD risk factors/scores, troponin I, dobutamine stress echocardiogram (DSE), and single-photon emission computed tomography (SPECT) to detect coronary stenosis ≥70 (CAD ≥ 70) per left heart catheterization (LHC). Thirty-day post-LT cardiac outcomes were also analyzed. Results: One hundred twenty-four of 148 (84%) patients underwent CAC, 106 (72%) DSE/SPECT, and 50 (34%) LHC. CAC ≥ 400 was found in 35 (28%), 100 to 399 in 17 (14%), and <100 in 72 (58%). LHC identified CAD ≥ 70% in 8 of 29 (28%), 2 of 9 (22%), and 0 of 4, respectively. Two acute coronary syndromes occurred after LT in a patient with CAC 811 (CAD < 70%), and one with CAC 347 (CAD ≥ 70%). No patients with CAC < 100 presented with acute coronary syndrome after LT. When using CAD ≥ 70% as primary endpoint of LT evaluation, CAC ≥ 346 was the only test showing predictive usefulness (negative predictive value 100%). Conclusions: CAC is a promising tool to guide CAD risk stratification and need for LHC during LT evaluation. Patients with a CAC < 100 can safely undergo LT without the need for LHC or cardiac stress testing, whereas a CAC < 346 accurately rules out significant CAD stenosis (≥70%) on LHC, outperforming other CAD risk-stratification strategies.

Coronary computed tomography angiography.

PURPOSE OF REVIEW: Significant limitations exist for traditional noninvasive cardiac imaging with regard to equivocal or indeterminate findings that result in repetitive testing or unnecessary referral to invasive coronary angiography (ICA). Recent hardware and software advances in multislice computed tomography angiography have achieved high spatial and temporal resolution to allow accurate noninvasive assessment of coronary arteries. This poses a paradigm shift in management of patients with suspected coronary artery disease (CAD). RECENT FINDINGS: Multicenter studies showed that coronary computed tomography angiography (CCTA) has a very high diagnostic accuracy, and, in particular, a very high negative predictive value (>98%) in detecting coronary stenosis when compared with ICA. In addition to its diagnostic ability, recent evidence-based outcome data have also validated the value of CCTA in predicting cardiac events. Absence of CAD on CCTA conveys excellent prognosis, whereas increasing disease severity and extent are associated with worsening outcome. Furthermore, CCTA allows comprehensive assessment of coronary stenosis, plaque burden, left ventricular morphology, function, perfusion and viability. One concern with CCTA is the issue of ionizing radiation exposure. Recent technical progress allows dramatic reduction of radiation dose. The newest generation scanner is capable of producing CCTA of diagnostic quality with a dose of less than 1 mSv. A multisociety guideline for appropriate clinical indications for cardiac computed tomography was recently published. SUMMARY: When used appropriately, CCTA has been established as a valid noninvasive imaging alternative to ICA in selected patients at low to intermediate risk of CAD.

Safety and efficacy of drug eluting stents compared with bare metal stents for saphenous vein graft interventions: a comprehensive meta-analysis of randomized trials and observational studies comprising 7,994 patients.

BACKGROUND: Saphenous vein graft (SVG) lesions remain amongst the most challenging lesions for percutaneous coronary intervention (PCI). It is unknown whether drug eluting stents (DES) are superior to bare metal stents (BMS) for such lesions. Our objective is to determine the safety and efficacy of DES compared with BMS for SVG lesions by performing a meta-analysis of clinical trials and observational studies. DATA SOURCES: PubMed, Cochrane Register of Controlled Trials, conference proceedings, and internet-based resources of clinical trials. STUDY SELECTION: Studies comparing DES vs. BMS for SVG lesions with at least>30 patients in each study reporting the outcomes of interest [death, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST), and the composite of death, TVR and MI (major adverse cardiac events; MACE)] with at least 6 months clinical follow-up. The primary outcome of interest was death. RESULTS: Two randomized trials, one subgroup analysis of a randomized trial and 26 observational studies comprising a total of 7,994 patients (4,187 patients in DES and 3,807 patients in BMS group) were included in the analysis. Mean follow-up duration was 21±11 months (6-48 months). In the overall population, MACE events were 19% in DES and 28% in BMS with a risk ratio (RR) of 0.7 (0.6, 0.8) P<0.00001. This effect of MACE was sustained in studies with >2 years follow-up with RR of 0.77 (0.65, 0.91) P=0.003. Death rate was 7.8% in DES and 9% in BMS with a RR of 0.82 (0.7, 0.97) P=0.02. MI rate was 5.7% in DES and 7.6% in BMS with RR of 0.72 (0.57, 0.91) P=0.007. TVR was 12% in DES and 17% in BMS with RR of 0.71 (0.59, 0.85) P=0.0002. ST was 1% in DES and 1.7 % in BMS RR of 0.61 (0.35, 1.06) P=0.08. Specifically in randomized controlled trials, DES were associated with no significant differences in overall mortality [RR=1.97; 95% confidence interval (CI), 0.17-23; P=0.58] or MI (RR=1.24; 95% CI, 0.3-5.5; P=0.78) compared with BMS. CONCLUSIONS: Based on the results of this meta-analysis, DES may be considered as a safe and efficacious option for the percutaneous intervention of SVG lesions.

Diagnostic performance of computed tomography angiography for differentiating ischemic vs nonischemic cardiomyopathy.

BACKGROUND: Although the use of computed tomography angiography (CTA) is considered "appropriate" to distinguish ischemic vs nonischemic etiology in patients with cardiomyopathy under the current clinical practice guideline, the evidence to support this has not been evaluated in larger scale studies. Thus, we conducted a meta-analysis of available studies published by October 2010 to address this question. METHODS: Studies evaluating the diagnostic accuracy of CTA versus invasive coronary angiography (as the gold standard) for significant coronary artery disease (CAD) detection (ischemic cardiomyopathy) in patients with no known history of CAD with significantly depressed left ventricular function (ejection fraction; EF < 35%) were selected for the meta-analysis. Sensitivity, specificity, positive, and negative likelihood ratios were calculated on per patient and per segment basis using random effects model (DerSimonian-Laird Method) for computing summary estimates and receiver operator curve (ROC) analysis for evaluating overall diagnostic accuracy. RESULTS: Six studies comprising 452 patients met the selection criteria for the meta-analysis. The pooled patient population was 62 ± 3 years old, with 29% females, 16% diabetics, and 43% with a history of hypertension. Mean EF was 32% ± 1%. The pooled summary estimate of sensitivity of CTA for diagnosis of ischemic cardiomyopathy was 98% [95% confidence interval (CI); 94% to 99%] and specificity was 97% (CI 94% to 98%), yielding a negative likelihood ratio of 0.06 (CI 0.02 to 0.13) and positive likelihood ratio of 20.85 (CI 12 to 36). There was no significant heterogeneity between studies for these estimates. The receiver operator curve analysis showed a robust discriminate diagnostic accuracy of ischemic etiology with an area under curve of 0.99 (P < .00001). CONCLUSION: CTA appears as a clinically applicable accurate diagnostic modality to exclude ischemic etiology in patients with cardiomyopathy of undetermined cause and this further supports the appropriateness of the use of CTA to determine the cause of new onset cardiomyopathy of unknown etiology.

Considerations for Maximizing the Exercise "Drug" to Combat Insulin Resistance: Role of Nutrition, Sleep, and Alcohol.

Insulin resistance is a key etiological factor in promoting not only type 2 diabetes mellitus but also cardiovascular disease (CVD). Exercise is a first-line therapy for combating chronic disease by improving insulin action through, in part, reducing hepatic glucose production and lipolysis as well as increasing skeletal muscle glucose uptake and vasodilation. Just like a pharmaceutical agent, exercise can be viewed as a "drug" such that identifying an optimal prescription requires a determination of mode, intensity, and timing as well as consideration of how much exercise is done relative to sitting for prolonged periods (e.g., desk job at work). Furthermore, proximal nutrition (nutrient timing, carbohydrate intake, etc.), sleep (or lack thereof), as well as alcohol consumption are likely important considerations for enhancing adaptations to exercise. Thus, identifying the maximal exercise "drug" for reducing insulin resistance will require a multi-health behavior approach to optimize type 2 diabetes and CVD care.

Lp-PLA(2) as a marker of cardiovascular diseases.

Inflammation lies at the base of endothelial dysfunction, eventually leading to plaque formation. The degree of inflammation defines the "vulnerability" of plaque to rupture. Numerous strategies have been adopted to identify and eventually treat high-risk vulnerable plaque. Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) has emerged as one such candidate marker of inflammation that may play a direct role in the formation of rupture-prone plaque. Epidemiologic studies have clearly demonstrated the prognostic ability of increased Lp-PLA(2) levels and their association with increased risk of future coronary and cerebrovascular events. Moreover, Lp-PLA(2) might have similar predictive power for both incident coronary heart disease in initially healthy individuals as well as for recurrent events in those with clinically manifest atherosclerosis. The latest evidence has also suggested its incremental value for risk determination over the well-established traditional risk factors and biomarkers in patients with congestive heart failure. These data support an integral role of Lp-PLA(2) activity in lipid peroxidation and cardiovascular risk assessment. This review summarizes the current body of evidence supporting the clinical utility of Lp-PLA(2) and its future applications in cardiovascular medicine.

The spectrum of atherosclerotic coronary artery disease in HIV patients.

The incidence of HIV is on the rise. With the advent of antiretroviral therapy, the average life expectancy of HIV patients has increased by several decades, but the increasing life expectancy has shifted the spectrum of HIV-associated morbidity and mortality away from opportunistic infections and toward chronic medical conditions. In fact, coronary artery disease has become the leading cause of mortality in patients with HIV. The pathophysiology of atherosclerosis in patients with HIV is very complex, including direct endothelial damage from viremia, a heightened overall state of inflammation from immune activation, higher prevalence and contribution from traditional atherosclerotic risk factors, and direct effects from antiretroviral therapy itself. This review focuses on the patterns, predictors, and pathophysiology of atherosclerotic disease in patients with HIV. In addition, the risks and benefits of evidence-based highly active antiretroviral therapy are critically evaluated.

Surge in Delayed Myocardial Infarction Presentations: An Inadvertent Consequence of Social Distancing During the COVID-19 Pandemic.

This case series summarizes our experience of delayed acute myocardial infarction presentations during the coronavirus disease-2019 pandemic predominantly driven by patient fear of contracting the virus in the hospital. Many presented with complications rarely seen in the primary percutaneous coronary intervention era including ventricular septal rupture, left ventricular pseudoaneurysm, and right ventricular infarction. (Level of Difficulty: Beginner.).

Predictive value of myocardial perfusion single-photon emission computed tomography and the impact of renal function on cardiac death.

BACKGROUND: Patients with chronic kidney disease (CKD) have worse cardiovascular outcomes than those without CKD. The prognostic utility of myocardial perfusion single-photon emission CT (MPS) in patients with varying degrees of renal dysfunction and the impact of CKD on cardiac death prediction in patients undergoing MPS have not been investigated. METHODS AND RESULTS: We followed up 1652 consecutive patients who underwent stress MPS (32% exercise, 95% gated) for cardiac death for a mean of 2.15+/-0.8 years. MPS defects were defined with a summed stress score (normal summed stress score <4, abnormal summed stress score>or=4). Ischemia was defined as a summed stress score >or=4 plus a summed difference score >or=2, and scar was defined as a summed difference score <2 plus a summed stress score >or=4. Renal function was calculated with the Modified Diet in Renal Disease equation. CKD (estimated glomerular filtration rate <60 mL . min(-1) . 1.73 m(-2)) was present in 36%. Cardiac death increased with worsening levels of perfusion defects across the entire spectrum of renal function. Presence of ischemia was independently predictive of cardiac death, all-cause mortality, and nonfatal myocardial infarction. Patients with normal MPS and CKD had higher unadjusted cardiac death event rates than those with no CKD and normal MPS (2.7% versus 0.8%, P=0.001). Multivariate Cox proportional hazards models revealed that both perfusion defects (hazard ratio 1.90, 95% CI 1.47 to 2.46) and CKD (hazard ratio 1.96, 95% CI 1.29 to 2.95) were independent predictors of cardiac death after accounting for risk factors, left ventricular dysfunction, pharmacological stress, and symptom status. Both MPS and CKD had incremental power for cardiac death prediction over baseline risk factors and left ventricular dysfunction (global chi(2) 207.5 versus 169.3, P<0.0001). CONCLUSIONS: MPS provides effective risk stratification across the entire spectrum of renal function. Renal dysfunction is also an important independent predictor of cardiac death in patients undergoing MPS. Renal function and MPS have additive value in risk stratisfying patients with suspected coronary artery disease. Patients with CKD appear to have a relatively less benign prognosis than those without CKD, even in the presence of a normal scan.

Early and long term outcome of rescue percutaneous coronary intervention (R-PCI): experience from a tertiary care center in Pakistan: outcome of rescue angioplasty in Pakistan.

BACKGROUND: Thrombolysis is the standard of care for STEMI in Pakistan. Failed thrombolysis has a very high morbidity and mortality. Rescue PCI then remains the only option to salvage the myocardium. We sought to analyze the angiographic, immediate and long term clinical outcome of patients undergoing Rescue PCI at our institution in Karachi, Pakistan. METHODS: 58 consecutive patients who underwent rescue PCI for failed thrombolysis between 2002 and 2005 were reviewed. Clinical characteristics, angiographic and procedural details with clinical outcomes including total mortality, recurrent angina, and repeat revascularization were studied. Sources included cardiac catheterization lab database, medical records and follow up at outpatient clinics. RESULTS: Rescue PCI was performed in 58 patients with a mean age 55 +/- 12 years with 47 (79%) male and 11 (21%) females. CAD risk factors were hypertension (53%), dyslipidemia (48%), smoking (34%) and diabetes (34%). 53% had anterior MI, 39% inferior and 8% had a lateral wall MI. The median time frames were: onset of chest pain to ER = 99 min, door to needle time = 35 min, ER to procedure start time = 250 min. The culprit vessels were: Left Anterior Descending (LAD) (53%), Right Coronary Artery (RCA) (32%) and Circumflex (CX) (15%). TIMI flow grades pre-procedural were 0/I = 52%, II = 34%, III = 14% and post procedure 0/I = 8%, II = 6%, III = 86%. The mean follow-up duration was 16.15 months at which 50 (86%) were alive and 43 (74.13%) had event free survival. CONCLUSION: Procedural success, event free survival and mortality in our series of Rescue PCI from Pakistan are comparable to recent international trials and registries. It should be considered as a reasonable option for patients with failed thrombolysis.

Incremental Prognostic Value of Post-Intervention Pd/Pa in Patients Undergoing Ischemia-Driven Percutaneous Coronary Intervention.

OBJECTIVES: This study sought to evaluate the prognostic value of post-percutaneous coronary intervention (PCI) distal coronary pressure to aortic pressure ratio (Pd/Pa) in predicting long-term clinical outcomes and to determine whether Pd/Pa combined with fractional flow reserve (FFR) post-intervention provides additional prognostic information superior to either marker alone. BACKGROUND: Post-PCI FFR has been shown to be a predictor of long-term outcomes in numerous studies. The role of post-PCI resting Pd/Pa has not been previously studied in this setting. METHODS: Consecutive patients undergoing PCI who had pre- and post-PCI Pd/Pa and FFR were followed for major adverse cardiovascular events (MACE) including death, myocardial infarction, and target vessel revascularization. RESULTS: A total of 574 patients were followed for 30 months (25th to 75th percentile 18 to 46 months). Using receiver-operating characteristic curve analysis post-stenting FFR cutoff of ≤0.86 had the best predictive accuracy of MACE (17% vs. 23%; log-rank p = 0.02), whereas post-stenting Pd/Pa ≤0.96 was the best predictor of MACE (15% vs. 24%; log rank p = 0.0006). There was a significant interaction between post-PCI Pd/Pa and FFR on MACE risk such that patients with Pd/Pa ≤0.96 and FFR ≤0.86 had the highest event rate (25%), whereas those with Pd/Pa >0.96 and FFR >0.86 had the lowest event rate (15%), which was not different from patients with Pd/Pa >0.96 and FFR ≤0.86 (17%). In a fully adjusted Cox regression analysis, Pd/Pa was an independent predictor of MACE (hazard ratio: 2.07; 95% confidence interval: 1.3 to 3.3; p = 0.002). CONCLUSIONS: Post-PCI resting Pd/Pa is a powerful prognostic tool for MACE prediction. It adds complementary and incremental risk stratification over established factors including post-PCI FFR.

Effectiveness of anemia and chronic kidney disease as predictors for presence and severity of coronary artery disease in patients undergoing stress myocardial perfusion study.

Chronic kidney disease (CKD) and anemia portend a higher risk of cardiac events and mortality. We sought to ascertain whether coronary artery disease (CAD) by myocardial perfusion single-photon emission computed tomography is more common in patients with CKD (glomerular filtration rate < or =60 ml/min/1.73 kg/m(2)) and/or anemia (hemoglobin level < or =13 g/L) and the impact of different degrees of CKD. One thousand five hundred eighty patients (mean age 65 +/- 10 years) underwent gated myocardial perfusion single-photon emission computed tomography and clinical evaluation. Patients were divided into 4 groups (group 1, no anemia/no CKD, n = 800; group 2, anemia/no CKD, n = 195; group 3, CKD/no anemia, n = 332; group 4, anemia/CKD, n = 253). Multivariate logistic regression analysis was undertaken to examine the association of these diagnoses with abnormal myocardial perfusion single-photon emission computed tomogram. Compared with patients with neither diagnosis, an abnormal scan was more common in those with anemia or CKD. Patients with anemia and CKD exhibited more severe CAD (mean summed stress score 6.8 vs 4.7, p <0.01). Established high-risk findings were more prevalent in patients with anemia and/or CKD, including a summed stress score > or =8, transient ischemic dilation, or a left ventricular ejection fraction < or =40% (group 1 28%, group 2 38%, group 3 38%, group 4 48%, all p values <0.01). Patients with moderate CKD demonstrated an increased risk of an abnormal scan (odds ratio 2.66, p <0.0001). After adjustment in multivariate analysis, anemia and CKD each remained predictors for an abnormal scan. The association was stronger in those with the 2 conditions (odds ratio for high-risk scan 1.89, p = 0.0002). In conclusion, in patients with suspected CAD, anemia and CKD are predictors of myocardial perfusion single-photon emission computed tomographic markers for worsened outcomes. The relation was independent of other risk factors, supporting the inclusion of anemia and CKD in global risk assessment for patients with suspected CAD.

Coronary steal due to bilateral internal mammary artery--pulmonary artery fistulas: a rare cause of chest pain after coronary artery bypass grafting.

A 54-year-old man with a history of coronary artery bypass grafting (CABG) presented with chest pain and was found to have non-ST-segment elevation myocardial infarction. Left heart catheterization with coronary angiography demonstrated 100% occlusion of the right internal mammary artery (IMA) to the right coronary artery graft in its midsegment and a patent left IMA to the left anterior descending graft. An unusually large extensive fistulous collateral formation was observed between the right IMA and the left IMA to the pulmonary arterial system, causing left to right shunting. His angina was attributed to substantial coronary steal caused by the shunt. The patient refused any further intervention or surgery and opted for medical treatment. As a complication of CABG, IMA to pulmonary artery (PA) fistulas are rare. Thus far, more than 20 cases have been reported; most have been unilateral. This is the second reported case to date of bilateral IMA-PA fistula formation after CABG. An IMA-PA fistula should be considered in the differential diagnosis of patients presenting with chest pain after CABG and can be diagnosed by selective angiography of IMA grafts.

Myocardial strain pattern in patients with cardiac amyloidosis secondary to multiple myeloma: a cardiac MRI feature tracking study.

Cardiac MRI is frequently used in the diagnosis of cardiac amyloidosis. Feature tracking is a novel method of analyzing myocardial strain at the myocardial borders. We investigated myocardial deformation mechanics of both the right and left ventricles in patients with multiple myeloma with suspected cardiac amyloidosis. Comprehensive strain analysis was performed in 43 patients with multiple myeloma and suspected cardiac amyloidosis. MRI strain by feature tracking was measured using 2D cardiac performance analysis MR software (Tomtec, Germany). Global longitudinal (GLS) and global circumferential (GLC) strain were calculated in endo and epicardium. In addition, right ventricular longitudinal strain was measured in the endocardium only. All patients later underwent endomyocardial biopsy. Average wall thickness in biopsy proven cardiac amyloidosis group (22 patients) was 1.4 ± 0.4 cm with wall thickness ≤ 1.2 cm in 36 %. LGE was present in all patients with biopsy confirmed disease. There was significantly decreased global longitudinal strain and strain rate in the epicardial and endocardial layers. Global circumferential strain was significantly reduced in the epicardial layer but not the endocardium. GLS was significantly decreased at the base in both layers compared to the mid and apical regions of the myocardium. However, the base to apex GLS gradient was suggestive of apical sparing in the endocardial layer among patients with amyloidosis (-8.2 ± 2 vs. -2.7 ± 1; p = 0.001) but not the epicardial layer. Apical sparing was evident even in those with normal thickness CA. This feature tracking MRI analysis sheds light on strain mechanics in a cohort of multiple myeloma associated cardiac amyloidosis with a significant number of cases with normal LV wall thickness and explains mechanism of apical sparing effect.

Correlation between Echocardiographic Pulmonary Artery Pressure Estimates and Right Heart Catheterization Measurement in Liver Transplant Candidates.

BACKGROUND: Patients undergoing liver transplant have worse outcomes in the presence of pulmonary hypertension. Correlation between echocardiography and catheterization derived pressures in this population is not well studied. Our study's aim is to show the relationship between pulmonary artery systolic pressure derived from transthoracic echo (ePASP) with pulmonary artery systolic pressure measured during right heart catheterization (cPASP). METHODS: Single center retrospective study, patients being evaluated for liver transplant (n = 31) who had an interpretable Doppler signal for ePASP and had right heart catheterization (RHC) measurements within 3 months constituted the study group. Control group (n = 49) consisted of patients who did not have liver disease. RESULTS: There was modest correlation between ePASP and cPASP (R = 0.58, p < 0.001) in LT candidates (n = 31) compared with the control group (R = 0.74, p < 0.001, n = 49). The 95% limits of agreement by Bland-Altman analysis ranged from +33.6 mmHg to -21.7 mmHg. Using receiver operating characteristic analysis, ePASP cut-off > 47 mmHg was 59% sensitive and 78% specific to diagnose pulmonary artery (PA) hypertension (mean PA pressure > 25 mmHg) in the LT candidates, while a similar cutoff performed well in the control group (cutoff > 43 mmHg, n = 47, 91% sensitive, 100% specific). CONCLUSIONS: Compared with other disease states, ePASP correlates modestly with cPASP in patients with advanced liver disease. A higher ePASP cutoff should be used to screen for pulmonary hypertension. A multi-center prospective study with simultaneous transthoracic echocardiography and RHC measurements is required to determine the best cut-off in this population.