Prognostic value of mean velocity at the pulmonary artery estimated by cardiovascular magnetic resonance as a prognostic predictor in a cohort of patients with new-onset heart failure with reduced ejection fraction.

BACKGROUND: Pulmonary hypertension (PH) conveys a worse prognosis in heart failure (HF), in particular when right ventricular (RV) dysfunction ensues. Cardiovascular magnetic resonance (CMR) non-invasively estimates pulmonary vascular resistance (PVR), which has shown prognostic value in HF. Importantly, RV to pulmonary artery (PA) coupling is altered early in HF, before significant rise in PV resistance occurs. The aim of this study was to assess the prognostic value of mean velocity at the pulmonary artery (mvPA), a novel non-invasive parameter determined by CMR, in HF with reduced ejection fraction (HFrEF) with and without associated PH. METHODS: Prospective inclusion of 238 patients admitted for new-onset HFrEF. MvPA was measured with CMR during index admission. The primary endpoint was defined as a composite of HF readmissions and all-cause mortality. RESULTS: During a median follow-up of 25 months, 91 patients presented with the primary endpoint. Optimal cut-off value of mvPA calculated by the receiver operator curve for the prediction of the primary endpoint was 9 cm/s. The primary endpoint occurred more frequently in patients with mvPA≤9 cm/s, as indicated by Kaplan-Meier survival curves; Log Rank 16.0, p <  0.001. Importantly, mvPA maintained its prognostic value regardless of RV function and also when considering mortality and HF readmissions separately. On Cox proportional hazard analysis, reduced mvPA≤9 cm/s emerged as an independent prognostic marker, together with NYHA III-IV/IV class, stage 3-4 renal failure and ischemic cardiomyopathy. CONCLUSIONS: In our HFrEF cohort, mvPA emerged as an independent prognostic indicator independent of RV function, allowing identification of a higher-risk population before structural damage onset. Moreover, mvPA emerged as a surrogate marker of the RV-PA unit coupling status.

Myocarditis in a young male affected with monkeypox infection: a case report.

Background: Concerns on monkeypox as a disease impacting global public health first emerged in May, 2022, and, since that time, has been identified in more than 50 countries. The condition mainly affects men who have sex with other men. Cardiac disease is a rare complication of monkeypox infection. Here, we describe a case of myocarditis in a young male subsequently diagnosed with monkeypox infection. Case summary: A 42-year-old male reported engaging in high-risk sexual behaviours with another male 10 days before presenting to the emergency department with chest pain, fever, maculopapular rash, and a necrotic chin lesion. Electrocardiography revealed diffuse concave ST-segment elevation associated with elevated cardiac biomarkers. Transthoracic echocardiography revealed normal biventricular systolic function without wall motion abnormalities. We excluded other sexually transmitted diseases or viral infections. Cardiac magnetic resonance imaging (MRI) findings suggested myopericarditis involving the lateral wall and adjacent pericardium. The results of polymerase chain reaction (PCR) tests of pharyngeal, urethral, and blood samples were positive for monkeypox. The patient was treated with high-dose non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine and he recovered soon. Discussion: Monkeypox infections are generally self-limited, with most patients experiencing benign clinical outcomes, no hospitalizations, and few complications. This is a rare report of monkeypox complicated with myopericarditis. Management with high-dose NSAIDs and colchicine relieved our patient's symptoms, suggesting a similar clinical outcome as other idiopathic or virus-related myopericarditis.

Influence of the medical treatment schedule in new diagnoses patients with heart failure and reduced ejection fraction.

AIMS: Heart failure (HF) guidelines recommend treating all patients with HF and reduced ejection fraction (HFrEF) with quadruple therapy, although they do not establish how to start it. This study aimed to evaluate the implementation of these recommendations, analyzing the efficacy and safety of the different therapeutic schedules. METHODS AND RESULTS: Prospective, observational, and multicenter registry that evaluated the treatment initiated in patients with newly diagnosed HFrEF and its evolution at 3 months. Clinical and analytical data were collected, as well as adverse reactions and events during follow-up. Five hundred and thirty-three patients were included, selecting four hundred and ninety-seven, aged 65.5 ± 12.9 years (72% male). The most frequent etiologies were ischemic (25.5%) and idiopathic (21.1%), with a left ventricular ejection fraction of 28.7 ± 7.4%. Quadruple therapy was started in 314 (63.2%) patients, triple in 120 (24.1%), and double in 63 (12.7%). Follow-up was 112 days [IQI 91; 154], with 10 (2%) patients dying. At 3 months, 78.5% had quadruple therapy (p < 0.001). There were no differences in achieving maximum doses or reducing or withdrawing drugs (< 6%) depending on the starting scheme. Twenty-seven (5.7%) patients had any emergency room visits or admission for HF, less frequent in those with quadruple therapy (p = 0.02). CONCLUSION: It is possible to achieve quadruple therapy in patients with newly diagnosed HFrEF early. This strategy makes it possible to reduce admissions and visits to the emergency room for HF without associating a more significant reduction or withdrawal of drugs or significant difficulty in achieving the target doses.

Mean Velocity of the Pulmonary Artery as a Clinically Relevant Prognostic Indicator in Patients with Heart Failure with Preserved Ejection Fraction.

BACKGROUND: Right ventricular (RV) to pulmonary circulation (PC) coupling can stratify prognosis in heart failure (HF). In this study, we assessed the prognostic role of the mean velocity of the pulmonary artery (mvPA) determined by cardiac magnetic resonance (CMR) in HF with preserved ejection fraction (HFpEF). METHODS: Inclusion of 58 HFpEF outpatients that underwent CMR with measurement of RV-PC coupling parameters including mvPA between 2016 and 2019. The primary combined endpoint was a composite of HF readmissions and all-cause mortality. RESULTS: Optimal cut-off value of mvPA calculated by receiver operating curve for the prediction of the primary endpoint was 9 cm/s. Over a median follow-up of 23 months (interquartile range: 24), 21 patients met the primary endpoint. The primary endpoint was more frequent in patients with mvPA ≤ 9 cm/s, as indicated by Kaplan-Meier survival curves; Log-Rank: 9.193, p = 0.02, regardless of RV dysfunction. On Cox multivariate analysis, mvPA ≤ 9 cm/s emerged as an independent prognostic predictor of the primary endpoint (HR: 4.11, 95% CI: 1.28-13.19, p = 0.017), together with left atrial area by CMR (HR: 1.08, 95% CI: 1.01-1.24, p = 0.034). CONCLUSIONS: In our HFpEF cohort, mvPA was associated with a higher rate of the primary endpoint, regardless of RV function, thus enabling identification of patients at higher risk of cardiovascular events before structural damage onset.

Hyperkalemia in heart failure patients in Spain and its impact on guidelines and recommendations: ESC-EORP-HFA Heart Failure Long-Term Registry.

INTRODUCTION AND OBJECTIVES: Hyperkalemia is a growing concern in the treatment of patients with heart failure and reduced ejection fraction because it limits the use of effective drugs. We report estimates of the magnitude of this problem in routine clinical practice in Spain, as well as changes in potassium levels during follow-up and associated factors. METHODS: This study included patients with acute (n=881) or chronic (n=3587) heart failure recruited in 28 Spanish hospitals of the European heart failure registry of the European Society of Cardiology and followed up for 1 year. Various outcomes were analyzed, including changes in serum potassium levels and their impact on treatment. RESULTS: Hyperkalemia (K+> 5.4 mEq/L) was identified in 4.3% (95%CI, 3.7%-5.0%) and 8.2% (6.5%-10.2%) of patients with chronic and acute heart failure, respectively, and was responsible for 28.9% of all cases of contraindication to mineralocorticoid receptor antagonist use and for 10.8% of all cases of failure to reach the target dose. Serum potassium levels were not recorded in 291 (10.8%) of the 2693 chronic heart failure patients with reduced ejection fraction. During follow-up, potassium levels increased in 179 of 1431 patients (12.5%, 95%CI, 10.8%-14.3%). This increase was directly related to age, diabetes, and history of stroke and was inversely related to history of hyperkalemia. CONCLUSIONS: This study highlights the magnitude of the problem of hyperkalemia in patients with heart failure in everyday clinical practice and the need to improve monitoring of this factor in these patients due to its interference with the possibility of receiving optimal treatment.

Late gadolinium enhancement-cardiovascular magnetic resonance identifies coronary artery disease as the aetiology of left ventricular dysfunction in acute new-onset congestive heart failure.

AIMS: We evaluated the ability of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance (CMR) to identify acute new-onset heart failure (HF) with left ventricular systolic dysfunction (LVSD), whether or not in relation to underlying coronary artery disease (CAD), in patients with no clinical evidence of associated ischaemic cardiomyopathy. METHODS AND RESULTS: Hundred consecutive patients admitted with acute new-onset decompensated HF and EF <40%, with no clinical or electrocardiographic data suggestive of CAD. The patients were classified according to the presence or absence of significant CAD (stenosis > or =70% in at least one major vessel). Twenty-one patients (21%) had significant CAD. Seventy-nine (79%) had no lesions. Eighteen of the 21 patients (85%) with CAD had subendocardial/transmural LGE. In the diagnosis of CAD, LGE has a sensitivity of 85.7% (95% CI, 80-91) and specificity of 92.4% (95% CI, 87-96), respectively, with a negative predictive value of 96% (95% CI, 90-99). It has an area under the receiver operating characteristic curve of 0.906 (95% CI, 0.814-0.998). CONCLUSION: In patients with new-onset HF and LVSD for whom there are no clinical and exploratory data suggestive of ischaemic heart disease, CMR with LGE is an excellent means of ruling out significant CAD and is a valid alternative to angiography.

Mean velocity of the pulmonary artery estimated by cardiac magnetic resonance as an early prognostic predictor in heart failure. / Velocidad media de la arteria pulmonar estimada por resonancia magnética cardiaca como predictor pronóstico precoz en insuficiencia cardiaca.

BACKGROUND AND OBJECTIVE: To identify early, non-invasive prognostic indicators in heart failure (HF), with and without associated pulmonary hypertension, by means of cardiac magnetic resonance, and oxidative stress and anti-inflammatory biomarkers such as TroloxTM (antioxidant status) and IL-10 (anti-inflammatory cytokine). PATIENTS AND METHODS: We prospectively included 70 patients admitted for new-onset HF. During index admission, mean velocity of the pulmonary artery (mvPA) was measured, and blood TroloxTM and IL-10 determined. The study sample was divided in two groups according to the optimal cut-off value for event prediction calculated by the ROC curve (mvPA=8cm/s), considering HF-readmission and all-cause mortality as the primary combined event. RESULTS: During a median follow-up of 290 days, 16 events occurred. In patients with preserved right ventricular (RV) function, mvPA ≤8cm/s was associated with a higher incidence of events during follow-up, Kaplan-Meier survival analysis (log rank 6.01, p=.014). MvPA did not add prognostic value when RV dysfunction was already established. TroloxTM concentration was lower in patients with mvPA ≤8cm/s. Higher IL-10 expression was associated with a lower incidence of cardiovascular events during follow-up. CONCLUSION: In HF patients, mvPA ≤8cm/s predicts a higher rate of cardiovascular events. Specifically, mvPA identifies a higher risk population among patients with preserved RV function, thus confirming its role as an early prognostic indicator. Lower TroloxTM concentration in the worse prognosis group concurs with previous studies on oxidative stress in pulmonary hypertension. Higher IL-10 concentration among patients free of cardiovascular events could be a reflection of its anti-inflammatory and thus protective role in HF.

Prognostic Value of Pulmonary Vascular Resistance by Magnetic Resonance in Systolic Heart Failure.

BACKGROUND: Pulmonary hypertension is associated with poor prognosis in heart failure. However, non-invasive diagnosis is still challenging in clinical practice. OBJECTIVE: We sought to assess the prognostic utility of non-invasive estimation of pulmonary vascular resistances (PVR) by cardiovascular magnetic resonance to predict adverse cardiovascular outcomes in heart failure with reduced ejection fraction (HFrEF). METHODS: Prospective registry of patients with left ventricular ejection fraction (LVEF) < 40% and recently admitted for decompensated heart failure during three years. PVR were calculated based on right ventricular ejection fraction and average velocity of the pulmonary artery estimated during cardiac magnetic resonance. Readmission for heart failure and all-cause mortality were considered as adverse events at follow-up. RESULTS: 105 patients (average LVEF 26.0 ± 7.7%, ischemic etiology 43%) were included. Patients with adverse events at long-term follow-up had higher values of PVR (6.93 ± 1.9 vs. 4.6 ± 1.7 estimated Wood Units (eWu), p < 0.001). In multivariate Cox regression analysis, PVR ≥ 5 eWu(cutoff value according to ROC curve) was independently associated with increased risk of adverse events at 9 months follow-up (HR2.98; 95% CI 1.12-7.88; p < 0.03). CONCLUSIONS: In patients with HFrEF, the presence of PVR ≥ 5.0 Wu is associated with significantly worse clinical outcome at follow-up. Non-invasive estimation of PVR by cardiac magnetic resonance might be useful for risk stratification in HFrEF, irrespective of etiology, presence of late gadolinium enhancement or LVEF.

mRNA PGC-1α levels in blood samples reliably correlates with its myocardial expression: study in patients undergoing cardiac surgery.

OBJECTIVE: Peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α) is a transcriptional coactivator that has been proposed to play a protective role in mouse models of cardiac ischemia and heart failure, suggesting that PGC-1α could be relevant as a prognostic marker. Our previous studies showed that the estimation of peripheral mRNA PGC-1α expression was feasible and that its induction correlated with the extent of myocardial necrosis and left ventricular remodeling in patients with myocardial infarction. In this study, we sought to determine if the myocardial and peripheral expressions of PGC-1α are well correlated and to analyze the variability of PGC-1α expression depending on the prevalence of some metabolic disorders. METHODS: This was a cohort of 35 consecutive stable heart failure patients with severe aortic stenosis who underwent an elective aortic valve replacement surgery. mRNA PGC-1α expression was simultaneously determined from myocardial biopsy specimens and blood samples obtained during surgery by quantitative PCR, and a correlation between samples was made using the Kappa index. Patients were divided into two groups according to the detection of baseline expression levels of PGC-1α in blood samples, and comparisons between both groups were made by chi-square test or unpaired Student's t-test as appropriate. RESULTS: Based on myocardial biopsies, we found that mRNA PGC-1α expression in blood samples showed a statistically significant correlation with myocardial expression (Kappa index 0.66, p<0.001). The presence of higher systemic PGC-1α expression was associated with a greater expression of some target genes such as silent information regulator 2 homolog-1 (x-fold expression in blood samples: 4.43±5.22 vs. 1.09±0.14, p=0.044) and better antioxidant status in these patients (concentration of Trolox: 0.40±0.05 vs. 0.34±0.65, p=0.006). CONCLUSIONS: Most patients with higher peripheral expression also had increased myocardial expression, so we conclude that the non-invasive estimation of mRNA PGC-1α expression from blood samples provides a good approach of the constitutive status of the mitochondrial protection system regulated by PGC-1α and that this could be used as prognostic indicator in cardiovascular disease.

Chest pain with minimal activities and flexion of trunk: a rare case of angina.

A 53-year-old woman presented with effort-induced chest pain during daily activities and similar symptoms with trunk flexion. A treadmill exercise test revealed a Mobitz II atrioventricular block. Coronarography and computed tomography confirmed the diagnosis of anomalous origin of the right coronary artery from the left coronary sinus, so surgical revascularization was indicated. We discuss the peculiarity of the clinical presentation and its possible pathogenic mechanism.

Blood PGC-1α Concentration Predicts Myocardial Salvage and Ventricular Remodeling After ST-segment Elevation Acute Myocardial Infarction.

INTRODUCTION AND OBJECTIVES: Peroxisome proliferator-activated receptor gamma coactivator 1α (PGC-1α) is a metabolic regulator induced during ischemia that prevents cardiac remodeling in animal models. The activity of PGC-1α can be estimated in patients with ST-segment elevation acute myocardial infarction. The aim of the present study was to evaluate the value of blood PGC-1α levels in predicting the extent of necrosis and ventricular remodeling after infarction. METHODS: In this prospective study of 31 patients with a first myocardial infarction in an anterior location and successful reperfusion, PGC-1α expression in peripheral blood on admission and at 72 hours was correlated with myocardial injury, ventricular volume, and systolic function at 6 months. Edema and myocardial necrosis were estimated using cardiac magnetic resonance imaging during the first week. At 6 months, infarct size and ventricular remodeling, defined as an increase > 10% of the left ventricular end-diastolic volume, was evaluated by follow-up magnetic resonance imaging. Myocardial salvage was defined as the difference between the edema and necrosis areas. RESULTS: Greater myocardial salvage was seen in patients with detectable PGC-1α levels at admission (mean [standard deviation (SD)], 18.3% [5.3%] vs 4.5% [3.9%]; P = .04). Induction of PGC-1α at 72 hours correlated with greater ventricular remodeling (change in left ventricular end-diastolic volume at 6 months, 29.7% [11.2%] vs 1.2% [5.8%]; P = .04). CONCLUSIONS: Baseline PGC-1α expression and an attenuated systemic response after acute myocardial infarction are associated with greater myocardial salvage and predict less ventricular remodeling.

[Diagnostic performance of surface electrocardiogram in early detection of chagasic cardiomyopathy]. / Rendimiento diagnóstico del electrocardiograma de superficie en la detección precoz de miocardiopatía chagásica.

BARCKGROUND AND OBJECTIVE: Contrast-enhanced cardiac magnetic resonance imaging (CMR) allows early detection of myocardial involvement by Trypanosoma cruzi infection. The aim of our study was to assess the diagnostic performance of the surface electrocardiogram (ECG) in the early detection of Chagas' cardiomyopathy (CCM) compared with CMR. METHODS: We included 43 asymptomatic patients (30 women, 42 ± 9.8 years), diagnosed of Chagas disease. The sample was divided into 2 groups according to the presence (n=17) or absence (n=26) of electrocardiographic abnormalities. All patients underwent CMR and late gadolinium enhancement (LGE) was used as a marker of early myocardial involvement. RESULTS: Six (14%) patients had a LGE significantly higher in the group who had electrocardiographic abnormalities (29 vs. 4%, P<.05). With CMR as the method of reference, the ECG had a sensitivity of 83% and a negative predictive value of 96% to detect CCM. CONCLUSION: ECG is a useful, inexpensive and globally available tool for the screening of CCM in asymptomatic patients but with proven myocardial involvement in CMR.

[Incorporation of cardiac rehabilitation programs and their characteristics in the Spanish National Health Service]. / Incorporation of cardiac rehabilitation programs and their characteristics in the Spanish National Health Service.

OBJECTIVES: To estimate the degree of incorporation of cardiac rehabilitation in the Spanish National Health Service, to describe the characteristics of the programs, and to report on the opinions of those responsible for them regarding their progress. PATIENTS AND METHOD: Cardiac rehabilitation centers were identified from different sources. A questionnaire which included items about coverage, resources, activities and services, selection of patients, and opinions was mailed to the heads of all units. RESULTS: Twelve public centers with cardiac rehabilitation programs were identified. Cardiac rehabilitation was offered to 53% of all eligible patients. All units treated patients with myocardial infarction, 64% treated those with heart failure; and 60% high risk patients. Approximately 10-19% of all patients were women. The physicians involved most frequently in programs were cardiologists; nonmedical professionals who participated most often were physiotherapists, and 64% of all units had a staff psychologist. Phase II rehabilitation was provided by all units, and phase III treatment was provided mainly by units that operated in coordination with out-patient services (45%). All units provided physical exercise training and counseling about the disease and risk factors, and 73% of them provided psychological support. The main reasons cited for providing rehabilitation were its efficacy and ability to prevent illness; and the main barriers to more widespread use were lack of resources and support. About three-fourths (73%) of all doctors interviewed thought that primary health care centers could play an important role in rehabilitation programs. CONCLUSIONS: Cardiac rehabilitation is poorly implemented in the Spanish National Health Service. The most significant differences between programs were related to the inclusion of high risk patients and with a diagnosis other than myocardial infarction, coordination with out-patient services, and provision of phase III rehabilitation.

Prognostic value of pulmonary vascular resistance estimated by cardiac magnetic resonance in patients with chronic heart failure.

AIMS: Pulmonary arterial hypertension is known to be related to worse prognosis in patients with heart failure (HF). Quantification of pulmonary vascular resistance (PVR) still requires invasive right heart catheterization. Recent studies have shown an accurate method for non-invasive estimation of PVR by cardiac magnetic resonance (CMR). Our aim was to evaluate the prognostic value of PVR calculated by CMR in patients with congestive HF. METHODS AND RESULTS: We calculated PVR by CMR in 132 patients [age 65.6 ± 13.1 years, left ventricular ejection fraction (LVEF) 35.1 ± 16.4%, ischaemic aetiology 40%] recently admitted for decompensated HF and derived to our cardiac imaging unit for diagnosis. Patients with cardiac events (readmission for HF or all-cause death) had higher values of PVR [6.77 ± 1.9 vs. 4.1 ± 1.6 Wood units (Wu), P < 0.001] during follow-up [mean 10.3 (1-31) months]. In multivariable Cox regression analysis, only a PVR ≥5.2 Wu [hazard ratio (HR) 4.27; 95% confidence interval (CI) 1.75-10.42; P < 0.001) and the presence of late gadolinium enhancement (LGE) on CMR (HR 2.24; 95% CI 1.03-4.86; P = 0.04) were independent predictors for adverse events at follow-up. CONCLUSION: Non-invasive estimation of PVR by CMR might be useful for risk stratification of patients with chronic HF, irrespective of aetiology or LVEF.

Clinical benefit of cardiac resynchronization therapy with a defibrillator in patients with an ejection fraction > 35% estimated by cardiac magnetic resonance.

INTRODUCTION AND OBJECTIVES: Cardiac resynchronization therapy with a defibrillator prolongs survival and improves quality of life in advanced heart failure. Traditionally, patients with ejection fraction > 35 estimated by echocardiography have been excluded. We assessed the prognostic impact of this therapy in a group of patients with severely depressed systolic function as assessed by echocardiography but with an ejection fraction > 35% as assessed by cardiac magnetic resonance. METHODS: We analyzed consecutive patients admitted for decompensated heart failure between 2004 and 2011. The patients were in functional class II-IV, with a QRS ≥ to 120 ms, ejection fraction ≤ 35% estimated by echocardiography, and a cardiac magnetic resonance study. We included all patients (n=103) who underwent device implantation for primary prevention. Ventricular arrhythmia, all-cause mortality and readmission for heart failure were considered major cardiac events. The patients were divided into 2 groups according to systolic function assessed by magnetic resonance. RESULTS: The 2 groups showed similar improvements in functional class and ejection fraction at 6 months. We found a nonsignificant trend toward a higher risk of all-cause mortality in patients with systolic function ≤ 35% at long-term follow-up. The presence of a pattern of necrosis identified patients with a worse prognosis for ventricular arrhythmias and mortality in both groups. CONCLUSIONS: We conclude that cardiac resynchronization therapy with a defibrillator leads to a similar clinical benefit in patients with an ejection fraction ≤ 35% or > 35% estimated by cardiac magnetic resonance. Analysis of the pattern of late gadolinium enhancement provides additional information on arrhythmic risk and long-term prognosis.

Incidental finding of migrated pacing lead fragment into pulmonary artery detected with CT.

This case shows a rare complication of a migrated atrial lead into the pulmonary artery incidentally detected during a comprehensive evaluation of coronary CT angiography.

Mean platelet volume is associated with infarct size and microvascular obstruction estimated by cardiac magnetic resonance in ST segment elevation myocardial infarction.

Mean platelet volume (MPV) is an indicator of platelet activation. High MPV has been recently considered as an independent risk factor for poor outcomes after ST-segment elevation myocardial infarction (STEMI). We analyzed 128 patients diagnosed with first STEMI successfully reperfused during three consecutive years. MPV was measured on admission and a cardiac magnetic resonance (CMR) exam was performed within the first week in all patients. Myocardial necrosis size was estimated by the area of late gadolinium enhancement (LGE), identifying microvascular obstruction (MVO), if present. Clinical outcomes were recorded at 1 year follow-up. High MPV was defined as a value in the third tertile (≥9.5 fl), and a low MPV, as a value in the lower two. We found a slight but significant correlation between MPV and infarct size (r = 0.287, P = 0.008). Patients with high MPV had more extensive infarcted area (percentage of necrosis by LGE: 17.6 vs. 12.5%, P = 0.021) and more presence of MVO (patients with MVO pattern: 44.4 vs. 25.3%, P = 0.027). In a multivariable analysis, hazard ratio for major adverse cardiac events was 3.35 [95% confidence interval (CI) 1.1-9.9, P = 0.03] in patients with high MPV. High MPV in patients with first STEMI is associated with higher infarct size and more presence of MVO measured by CMR.

Gerbode-type left ventricular outflow tract to right atrial fistula complicating prosthetic aortic valve replacement identified by cardiac computed tomographic angiography.

Acquired left ventricular-right atrial communication (Gerbode-type defect) is a rare complication of infective endocarditis. Although transesophageal echocardiography remains the technique of choice for the evaluation of complications of endocarditis this case highlights the usefulness of cardiac computed tomography in this scenario, particularly in cases where assessment of coronary anatomy is required before surgery.

Etiological diagnosis of left ventricular dysfunction: computed tomography compared with coronary angiography and cardiac magnetic resonance.

INTRODUCTION AND OBJECTIVES: To evaluate the capability of multidetector computed tomography to diagnose the coronary etiology of left ventricular dysfunction compared with using invasive coronary angiography and magnetic resonance. METHODS: Forty consecutive patients with left ventricular dysfunction of uncertain etiology underwent invasive coronary angiography and contrast magnetic resonance. All patients were evaluated with multidetector computed tomography including coronary calcium presence and score, noninvasive coronary angiography, and myocardial tissue assessment. RESULTS: The sensitivity and specificity of the presence of coronary calcium to identify left ventricular dysfunction was 100% and 31%, respectively. If an Agatston calcium score of >100 is taken, specificity increases to 58% with sensitivity still 100%. Sensitivity and specificity for coronary angiography by multidetector computed tomography was 100% and 96%, respectively; for identifying necrosis in contrast acquisition it was 57% and 100%, respectively; and in late acquisition, 84% and 96%, respectively. To identify coronary ventricular dysfunction with necrosis, the sensitivity and specificity was 92% and 100%, respectively. CONCLUSIONS: Of all the diagnostic tools available in multidetector computed tomography, coronary angiography is the most accurate in determining the coronary origin of left ventricular dysfunction. A combination of coronary angiography and myocardial tissue study after contrast allows a single test to obtain similar information compared with the combination of invasive coronary angiography and contrast magnetic resonance.