Feasibility of digital atrial fibrillation screening in an elderly population : The Ulm heart rhythm weeks.

AIMS: Atrial fibrillation (AF) screening in risk populations has the potential to prevent strokes. The authors tested the feasibility of a digital program with initial photoplethysmographic (PPG) self-screening and cardiologist-attended electrocardiographic (ECG) confirmation of screen-positive cases. METHODS: Inhabitants of the city of Ulm aged ≥ 65 years were invited to participate. After digital consent, participants were given access to a smartphone application for 14 days of self-screening (two recordings per day recommended). Screen-positive participants without known AF were invited to present to a cardiologist for AF confirmation with a 14-day ECG event recorder. PPG recordings were first analyzed by algorithm using a combination of linear and non-linear methods. The quality of pathological (classified by algorithm) PPG and all ECG recordings were checked by a telecare service. Primary outcomes included adherence to the screening protocol defined as the proportion of participants performing at least 14 PPG recordings (or until documentation of absolute arrhythmia) and the proportion of pathological PPG and all ECG recordings rejected by the telecare center. RESULTS: A total of 215 participants registered. Of these, 204 (95%) performed at least one recording and 169 (79%) reached the performance target of two sufficient measurements per day; 75 PPG recordings were automatically classified as pathological by algorithm; 14 (19%) were rejected by the telecare service due to poor quality. Of the 12 participants with a suspected first diagnosis of AF, five visited a cardiologist as part of the study. Of 1090 ECG recordings obtained, 390 (36%) were qualified as non-diagnostic. AF was confirmed in three cases. CONCLUSIONS: A digital AF screening program with initial self-screening and referral of screen-positive cases to a cardiologist-attended ECG-confirmation service is feasible with meaningful results in an elderly risk population. However, the availability of the target population of persons > 65 years of age for such a digital screening program appears to be limited despite extensive public relations activities.

Isolated Whipple's endocarditis: an underestimated diagnosis that requires molecular analysis of surgical material.

Tropheryma whipplei is known as the bacterium that causes Whipple's disease, a rare systemic illness typically affecting gastrointestinal tract, joints, and central nervous system. In addition, T whipplei infection may present as an isolated endocarditis. Although previously regarded as a rare condition, T whipplei has been recognized as a major cause of culture-negative endocarditis when integrating specific molecular analysis of surgical material into the diagnostic algorithm. Here, we report the case of a 67-year-old man undergoing mitral valve replacement due to T whipplei endocarditis, and discuss diagnostic and therapeutic implications.

Prospective randomised trial evaluating a paclitaxel-coated balloon in patients treated with endothelial progenitor cell capturing stents for de novo coronary artery disease.

BACKGROUND: Percutaneous coronary intervention with stent implantation is limited by the occurrence of re-stenosis and the risk of stent thromboses. OBJECTIVE: To define the impact of paclitaxel-coated balloon angioplasty plus endothelial progenitor cell capturing (EPC) stent implantation in de novo coronary artery disease. This combination may reduce neointimal proliferation within the EPC stent and address the risk of stent thrombosis by facilitating rapid endothelialisation. METHODS: In this prospective single-blind multicentre randomised trial, 120 patients with a de novo lesion in a native coronary artery were randomly assigned to undergo treatment with paclitaxel-coated balloon plus EPC stent or EPC stent alone. Dual antiplatelet therapy was prescribed for 3 months. Angiographic follow-up was scheduled at 6 months. The primary endpoint was in-stent late lumen loss. The secondary clinical endpoint was a composite of death from a cardiac cause, myocardial infarction attributed to the target vessel or target lesion revascularisation. RESULTS: There was no difference in patient baseline characteristics or procedural results. The angiographic follow-up rate was 96%. Treatment with paclitaxel-coated balloon plus EPC stent was superior to EPC stent alone, with an in-stent late loss of 0.34±0.45 mm versus 0.88±0.48 mm (p<0.001). The re-stenosis rate was reduced from 23.2% to 5.1% (p=0.006) and the clinical endpoint was reduced from 17.2% to 4.8% (p=0.039). There was no definite or probable stent thrombosis. CONCLUSIONS: Paclitaxel-coated balloon plus EPC stent implantation is superior to EPC stent implantation alone for treatment of de novo coronary artery disease. TRIAL REGISTRATION: NCT00732953.

Myocardial scar extent evaluated by cardiac magnetic resonance imaging in ICD patients: relationship to spontaneous VT during long-term follow-up.

Patients with ischemic cardiomyopathy have an increased risk for ventricular arrhythmia, since myocardial infarction can be the substrate for re-entrant arrhythmias. Contrast-enhanced cardiac magnetic resonance imaging (CMR) has proven to reliably quantify myocardial infarction. Aim of our study was to evaluate correlations between functional and contrast-enhanced CMR findings and spontaneous ventricular tachy-arrhythmias in patients with ischemic cardiomyopathy who underwent implantable cardioverter-defibrillator (ICD) therapy. Forty-one patients with ischemic cardiomyopathy and indication for ICD therapy underwent cine and late gadolinium enhancement CMR for quantification of left ventricular volumes, function and scar tissue before subsequent implantation of ICD device. During a follow-up period of 1184 ± 442 days 68 monomorphic and 14 polymorphic types of ventricular tachycardia (VT) could be observed in 12 patients. Patients with monomorphic VT had larger scar volumes (25.3 ± 11.3 vs. 11.8 ± 7.5% of myocardial mass, P < 0.05) than patients with polymorphic VT. Moreover myocardial infarction involved more segments in the LAD perfusion territory (86 vs. 20%, P < 0.05) than in patients with polymorphic VT. Patients with spontaneous monomorphic VT during the long-term follow-up period had more infarcted tissue, which was more often present in the LAD perfusion territory than patients with polymorphic events. These data strengthen the diagnostic benefit of CMR in patients with ischemic cardiomyopathy. CMR may be used for better risk stratification in patients with ischemic cardiomyopathy undergoing ICD therapy.

Detection of long-term progression of myocardial fibrosis in Duchenne muscular dystrophy in an affected family: a cardiovascular magnetic resonance study.

BACKGROUND: Detection of myocardial fibrosis and left ventricular dysfunction in Duchenne muscular dystrophy (DMD) is the corner stone for further therapeutic studies. Little is known about the ability of cardiac magnetic resonance imaging (CMR) to evaluate progression of myocardial fibrosis. Aim of our study was to provide CMR data in a previously genotyped DMD family and to evaluate whether progression of myocardial fibrosis could be visualized. METHODS AND RESULTS: DMD genotypes were available in 14 family members. CMR was performed in 4/5 carrier females, in 2/2 affected males and in one healthy family member with normal genotype. Functional images and late gadolinium enhanced (LGE) images in contiguous short-axis orientation were acquired at baseline and follow-up of 1231 days CMR examination could be repeated in three carrier females, in one affected male and in the healthy subject previously scanned. Mean decrease of left ventricular ejection fraction during the follow-up period was 10.5±11.0%, mean progression of LGE volume 11.7±9.5%. CONCLUSIONS: Myocardial fibrosis seems to occur prior to global left ventricular dysfunction in DMD diseased males and carrier females. CMR could be used to evaluate progression of myocardial fibrosis and left ventricular function and may thus serve as an important diagnostic tool in the evaluation of therapeutical options in DMD.

Blood oxygen level-dependent magnetic resonance imaging using T2-prepared steady-state free-precession imaging in comparison to contrast-enhanced myocardial perfusion imaging.

BACKGROUND: Diagnosis of inducible myocardial ischemia is important for deciding further diagnosis and therapy in coronary artery disease (CAD). Blood oxygen level-dependent (BOLD) cardiac magnetic resonance imaging (CMR) is a potential method to evaluate myocardial perfusion reserve alternatively to first-pass perfusion using contrast agents. METHODS AND RESULTS: We imaged 46 patients with suspected CAD on a 1.5 T whole-body CMR scanner using a T2-prepared steady-state free-precession (SSFP) BOLD-sensitive sequence and a SSFP-based first-pass sequence. All patients were scanned during rest and after 3 min of adenosine infusion (140 µg/kg/min). For myocardial first-pass visualization 0.1 mmol/kg Gadolinium-based contrast agent was used. In 90 myocardial segments a first-pass perfusion deficit could be seen. Relative BOLD signal increase was significantly lower in patients with perfusion deficits compared to patients without perfusion deficits (p < 0.0001). Patients with non-transmural and with transmural first-pass perfusion deficit also differed significantly for BOLD signal increase (p < 0.0001). ROC analysis showed an area under the curve of 0.83 for the T2-prepared SSFP sequence regarding detection of inducible perfusion deficit. CONCLUSIONS: T2-prepared BOLD imaging allows for visualization of myocardial perfusion reserve in a clinical setting without additional use of contrast agents.

Diagnostic performance of magnetic resonance first pass perfusion imaging is equally potent in female compared to male patients with coronary artery disease.

BACKGROUND: Noninvasive diagnosis of coronary artery disease (CAD) in women is crucial because of a lower prevalence of CAD in premenopausal women, different cardiac risk profile and pattern of CAD, lower exercise tolerance and more atypical symptoms compared to men. Therefore, we tested the diagnostic power of cardiac magnetic resonance first pass perfusion imaging (CMR-FPPI) for the diagnosis of significant coronary stenoses in females versus males. METHODS AND RESULTS: 256 consecutive patients, 77 females and 179 males with atypical or typical chest pain and intermediate risk of CAD were studied by coronary angiography and CMR-FPPI (1.5T Intera CV). A three-slice, short-axis perfusion scan with a saturation prepulse was performed during infusion of adenosine and at rest followed by late enhancement imaging for myocardial scar. Gadolinium-DTPA was administered at 0.1 mmol/kg body weight. Perfusion images were visually analysed, coronary stenoses by quantitative coronary angiography. Sensitivity, specificity and accuracy of CMR-FPPI for detection of a significant coronary artery stenosis (> or = 50% luminal narrowing) in the entire group were 91.3, 81.7 and 88.6%, the corresponding values for females were 90.9, 90.6 and 90.8% and for males 91.4, 74.4 and 87.7%, and in the subgroup of females with suspected primary CAD 83.3, 96.0 and 93.6%, and for suspected progression 92.1, 71.4 and 88.9%. CONCLUSION: Diagnostic accuracy of CMR-FPPI is very high in women with intermediate risk of CAD and comparable or in part superior to results in males. With the advantage of the absence of radiation exposure and high spatial and temporal resolution, CMR-FPPI has the potential to become the preferred imaging test to select women for coronary angiography.

Combined assessment of myocardial perfusion and late gadolinium enhancement in patients after percutaneous coronary intervention or bypass grafts: a multicenter study of an integrated cardiovascular magnetic resonance protocol.

OBJECTIVES: We sought to assess the accuracy of an integrated cardiac magnetic resonance (CMR) protocol for the diagnosis of relevant coronary artery or bypass graft stenosis in patients with suspected coronary artery disease (CAD) or with previously performed percutaneous coronary intervention (PCI) or coronary bypass graft surgery (CABG). BACKGROUND: CMR is suitable for diagnosing inducible myocardial ischemia in patients with suspected CAD and has been proven to be a helpful diagnostic tool for decision of further treatment. However, little is known about its diagnostic accuracy in patients with known CAD who previously were treated by PCI or CABG. METHODS: A total of 477 patients with suspected CAD, 236 with previous PCI, and 110 after CABG referred for coronary X-ray angiography (CXA) underwent an integrated CMR examination before CXA. Myocardial ischemia was assessed using first-pass perfusion after vasodilator stress with adenosine (140 microg/kg/min for 3 min) using gadolinium-based contrast agents (0.1 mmol/kg). Late gadolinium enhancement (LGE) was assessed 10 min after a second contrast bolus. RESULTS: CXA demonstrated a relevant coronary vessel stenosis (> or =70% luminal reduction) in 313 (38%) patients using quantitative coronary analysis. The combination of CMR perfusion and LGE assessment for detecting a relevant coronary stenosis in patients with suspected CAD yielded sensitivity and specificity of 0.94 and 0.87, in PCI patients 0.91 and 0.90, and in CABG patients 0.79 and 0.77, respectively. CONCLUSIONS: A combined CMR protocol for the assessment of myocardial perfusion and LGE is feasible for the detection of relevant coronary vessel stenosis even in patients who previously were treated by PCI or CAG in a routine clinical setting. However, diagnostic accuracy is reduced in patients with CABG. This could be due to different flow and perfusion kinetic. Further studies are needed to optimize the clinical protocols especially in post-surgical patients.

Cardiac phase-specific shimming (CPSS) for SSFP MR cine imaging at 3 T.

The application of steady-state-free-precession (SSFP) techniques at 3 T systems is still limited by their sensitivity to magnetic field inhomogeneities. Especially during imaging of the heart, the arising signal voids and distortions in the myocardium currently often limit the diagnostic value of the resulting images. Dedicated shim systems providing higher order shimming capabilities have been applied to improve the field homogeneity across the heart. In this study, the potential benefit of applying a cardiac phase-specific shim (CPSS) was investigated. The cardiac phase dependence of the magnetic field distortions over the heart was assessed and the potential gain in field homogeneity by CPSS was evaluated. CPSS was successfully applied in volunteers and yielded significant improvement in the main magnetic field homogeneity over the entire cardiac cycle.

Impact of percutaneous device implantation for closure of patent foramen ovale on valve insufficiencies.

BACKGROUND: In patients with percutaneous device implantation for closure of patent foramen ovale (PFO), a 10% incidence of new or worsened aortic regurgitation within 12 months has been reported with echocardiography. Cardiac magnetic resonance imaging is a powerful noninvasive tool to quantify volume and fraction of valve insufficiencies. We studied the acute and long-term impact of percutaneous device implantation for PFO closure on valve insufficiencies in cardiac magnetic resonance imaging. METHODS AND RESULTS: Sequential cardiac magnetic resonance imaging studies were performed in 102 patients with cryptogenic ischemic events. Cardiac magnetic resonance imaging was performed before PFO closure, the day after device implantation, and at 12 months of follow-up. There was no difference in volumetric and hemodynamic parameters before PFO closure compared with 12 months of follow-up. With a cutoff for relevant regurgitation fraction of 5%, there were no statistically significant differences in regurgitation fraction of the semilunar and atrioventricular valves. The median fraction of aortic valve insufficiency was 3.9% (interquartile range [IQR] 2.0% to 5.1%) before PFO closure, 5.4% (IQR 4.1% to 5.9%) after device implantation, and 4.3% (IQR 3.3% to 6.0%) at 12 months of follow-up. The size and type of the occluder had no impact on aortic valve insufficiency. Median regurgitation fraction for the pulmonary valve was 3.6% (IQR 2.4% to 6.7%) before intervention, 7.3% (IQR 5.1% to 8.2%) after occluder implantation and 5.8% (IQR 4.8% to 7.4%) at 12 months of follow-up. Values for the mitral valve were 3.1% (IQR 1.4% to 6.0%), 5.5% (IQR 3.5% to 7.3%), and 3.8% (IQR 1.5% to 7.9%) and for the tricuspid valve were 5.4% (IQR 0.1% to 8.8%), 5.8% (IQR 1.4% to 9.2%), and 6.0% (IQR 1.1% to 8.4%), respectively. CONCLUSIONS: Percutaneous PFO closure with device implantation has no impact on valve insufficiencies as determined by cardiac magnetic resonance imaging.

Local excitation black blood imaging at 3T: application to the carotid artery wall.

A novel approach for imaging large sections of the carotid artery wall at isotropic spatial resolution is presented. Local excitation by means of 2D excitation pulses was combined with a diffusion-prepared segmented steady-state black-blood gradient echo technique enabling the assessment of the carotid arterial wall over a range of up to 15 cm. The carotid arteries of five healthy volunteers were imaged with the proposed technique. Signal-to-noise ratio (SNR), wall-lumen contrast-to-noise ratio (CNR), and vessel dimensions were assessed and compared to conventional excitation techniques. In all experiments black-blood contrast could be realized over the covered carotid arteries with similar SNR and CNR as the conventional technique covering the region of the bulbus only. The proposed technique enables the time-efficient coverage of the carotid arteries without compromising wall-lumen CNR and geometrical accuracy. Furthermore, the proposed technique appears to be less sensitive to motion and swallowing artifacts due to the local character of the excitation.

Whole-heart coronary vein imaging: a comparison between non-contrast-agent- and contrast-agent-enhanced visualization of the coronary venous system.

The feasibility of three-dimensional (3D) whole-heart imaging of the coronary venous (CV) system was investigated. The hypothesis that coronary magnetic resonance venography (CMRV) can be improved by using an intravascular contrast agent (CA) was tested. A simplified model of the contrast in T(2)-prepared steady-state free precession (SSFP) imaging was applied to calculate optimal T(2)-preparation durations for the various deoxygenation levels expected in venous blood. Non-contrast-agent (nCA)- and CA-enhanced images were compared for the delineation of the coronary sinus (CS) and its main tributaries. A quantitative analysis of the resulting contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) in both approaches was performed. Precontrast visualization of the CV system was limited by the poor CNR between large portions of the venous blood and the surrounding tissue. Postcontrast, a significant increase in CNR between the venous blood and the myocardium (Myo) resulted in a clear delineation of the target vessels. The CNR improvement was 347% (P < 0.05) for the CS, 260% (P < 0.01) for the mid cardiac vein (MCV), and 430% (P < 0.05) for the great cardiac vein (GCV). The improvement in SNR was on average 155%, but was not statistically significant for the CS and the MCV. The signal of the Myo could be significantly reduced to about 25% (P < 0.001).

Valvular strands and ischemic stroke.

We report the case of a previously healthy 47-year-old woman suffering an acute embolic stroke in the left middle cerebral artery distribution. A filiform structure along the line of the aortic valve was first identified by transesophageal echocardiography, leading to the diagnosis of a valvular strand. These masses are thought to represent giant Lambl's excrescences, although differential diagnoses include several benign cardiac tumors, e.g. papillary fibroelastoma. Valvular strands have previously been associated with embolic events including stroke, although exact pathogenetic mechanisms and further patient management have not yet been fully established. This case report additionally provides a short overview of the currently existing literature. As a conclusion, standard recommendations for patient management and treatment cannot be derived from currently available evidence.

Cardiac magnetic resonance imaging and transesophageal echocardiography in patients with transcatheter closure of patent foramen ovale.

OBJECTIVES: We studied the value of cardiac magnetic resonance imaging (CMRI) before and after closure of patent foramen ovale (PFO) in patients with cryptogenic ischemic events. BACKGROUND: Cardiac magnetic resonance imaging is a powerful noninvasive tool for detailed assessment of cardiac anatomy and function. The relevance of CMRI compared with transesophageal echocardiography (TEE) in patients undergoing transcatheter PFO closure has not been evaluated so far. METHODS: Contrast-enhanced CMRI and TEE were performed in 75 patients before and after PFO closure. Twelve months after PFO closure, both imaging techniques were repeated in 61 patients with contrast application. To determine provokable atrial right-to-left shunting in CMRI, we applied a contrast-enhanced perfusion imaging technique. Detection of atrial septal aneurysm (ASA) was achieved by means of a high-resolution cine imaging technique. RESULTS: Before PFO closure, ASA was seen with CMRI in 28 of 75 cases (37.3%), compared with 47 of 75 (62.7%) cases using TEE. There were a total of 211 CMRI studies with a corresponding TEE performed in 75 patients. No shunt was present in 107 of 211 studies with both techniques. Contrast-enhanced right-to-left shunting was detected by CMRI in 48 of 72 (66.6%) cases with moderate or severe shunts seen with TEE, but only in 6 of 32 (18.8%) studies with mild shunts with TEE. Anomalous venous returns were excluded in all patients. In two patients, coronary anomalies were seen. CONCLUSIONS: The present CMRI technique is inferior to TEE in detection of contrast-enhanced right-to-left shunting and identification of ASA.

Reproducibility of the proximal flow convergence method in mitral and tricuspid regurgitation.

BACKGROUND: The follow-up of patients with mitral and tricuspid regurgitation is important for their clinical treatment. We aimed to evaluate the reproducibility of the flow convergence method in mitral and tricuspid regurgitation. METHODS: The proximal flow convergence region was imaged with color Doppler ultrasound scanning echocardiography in 83 patients with mitral regurgitation, tricuspid regurgitation, or both. Proximal isovelocity surface area radii for aliasing velocities of 27 to 29 cm/s and 41 to 43 cm/s were repeatedly measured by the same experienced investigator on different days and by experienced and less experienced investigators at 1 day. RESULTS: In mitral regurgitation, the intraobserver variability rate was 0.2% +/- 13.5% (2.8% +/- 13.3%) and the interobserver variability was 0.1% +/- 13.8% (1.7% +/- 18.0%) for an aliasing velocity of 27 to 29 cm/s (41-43 cm/s). For the aliasing velocity of 27 to 29 cm/s (41-43 cm/s), the 95% ranges for change of the proximal isovelocity surface area radii were +/- 2.7 mm (+/- 1.8 mm) for measurements repeated by the same investigator and +/- 2.7 mm ( +/- 2.4 mm) for different investigators. Interobserver variability was independent of the investigators' experience. Similar data were achieved in tricuspid regurgitation. CONCLUSIONS: The proximal flow convergence method is acceptably reproducible in mitral and tricuspid regurgitation independent of the investigators experience. For the aliasing velocity of 27 to 29 cm/s (41-43 cm/s), the proximal isovelocity surface area radius has to change for >2.7 (2.4) mm before an altered severity of mitral or tricuspid regurgitation in a single patient can be assumed.