Prognostic value of a new semiquantitative score system for adenosine stress myocardial perfusion by CMR.

OBJECTIVES: Cardiovascular magnetic resonance (CMR) provides information on myocardial ischemia through stress perfusion studies. In clinical practice, the grading of induced perfusion defects is performed by visual estimation of their extension. The aim of our study is to devise a score of the degree of ischemia and to test its prognostic value. METHODS: Between 2009 and 2011, patients with diagnosed or suspected coronary artery disease underwent stress perfusion CMR. A score of ischemic burden was calculated on the basis of (1) stress-induced perfusion defect, (2) persistence, (3) transmurality, and (4) stress-induced contractile defect. Follow-up was censored after 4 years and primary end-point was defined by a composite of death, heart failure episode, acute coronary syndrome, and ventricular arrhythmias. Univariate and multivariate logistic regressions were used to assess the strength of the association between the CMR ischemic variables, and the composite outcome. RESULTS: Forty-four of the 128 patients (34%) presented with adverse events, while 84 (66%) did not. Sixty-one patients (48%) had negative perfusion studies while 67 (52%) showed perfusion defect. Patients with positive perfusion studies and adverse events (n = 39) had higher number of segments with persistent defect (3.3 vs 1.3, p = 0.001) and highest score (19.6 vs 13.3 p = 0.012) than patients with positive perfusion studies and absence of events (n = 28). The number of segments with persistent defect showed the strongest predictive value of adverse events (OR 1.54; CI 1.19-2.00; p < 0.001). CONCLUSIONS: The score of ischemic burden proposed herein has prognostic value. Persistence of a perfusion defect has the strongest impact on prognosis. KEY POINTS: • Cardiovascular magnetic resonance provides information on myocardial ischemia by visual estimation of the presence of perfusion defects induced by stress. • There is not a standardized method for grading perfusion defects which, in practice, is performed by visual estimation of their extension. • As proven in this study, the integration of several parameters of perfusion defects (in addition to extension) into a semiquantitative score has prognostic value.

ß3 adrenergic agonist treatment in chronic pulmonary hypertension associated with heart failure (SPHERE-HF): a double blind, placebo-controlled, randomized clinical trial.

AIMS: Pulmonary hypertension (PH) associated with left heart disease is an increasingly prevalent problem, orphan of targeted therapies, and related to a poor prognosis, particularly when pre- and post-capillary PH combine. The current study aimed to determine whether treatment with the selective ß3 adrenoreceptor agonist mirabegron improves outcomes in patients with combined pre- and post-capillary PH (CpcPH). METHODS AND RESULTS: The ß3 Adrenergic Agonist Treatment in Chronic Pulmonary Hypertension Secondary to Heart Failure (SPHERE-HF) trial is a multicentre, randomized, parallel, placebo-controlled clinical trial that enrolled stable patients with CpcPH associated with symptomatic heart failure. A total of 80 patients were assigned to receive mirabegron (50 mg daily, titrated till 200 mg daily, n = 39) or placebo (n = 41) for 16 weeks. Of them, 66 patients successfully completed the study protocol and were valid for the main analysis. The primary endpoint was the change in pulmonary vascular resistance (PVR) on right heart catheterization. Secondary outcomes included the change in right ventricular (RV) ejection fraction by cardiac magnetic resonance or computed tomography, other haemodynamic variables, functional class, and quality of life. The trial was negative for the primary outcome (placebo-corrected mean difference of 0.62 Wood units, 95% confidence interval [CI] -0.38, 1.61, p = 0.218). Patients receiving mirabegron presented a significant improvement in RV ejection fraction as compared to placebo (placebo-corrected mean difference of 3.0%, 95% CI 0.4, 5.7%, p = 0.026), without significant differences in other pre-specified secondary outcomes. CONCLUSIONS: SPHERE-HF is the first clinical trial to assess the potential benefit of ß3 adrenergic agonists in PH. The trial was negative since mirabegron did not reduce PVR, the primary endpoint, in patients with CpcPH. On pre-specified secondary outcomes, a significant improvement in RV ejection fraction assessed by advanced cardiac imaging was found, without differences in functional class or quality of life.

Ruling out coronary artery disease with noninvasive coronary multidetector CT angiography before noncoronary cardiovascular surgery.

PURPOSE: To assess the usefulness of preoperative coronary computed tomographic (CT) angiography in the detection of coronary artery disease (CAD) in nonselected patients scheduled to undergo noncoronary cardiovascular surgery to avoid unnecessary invasive coronary angiography (ICA). MATERIALS AND METHODS: The institutional review board approved the study protocol; informed consent was given. This prospective study involved 161 consecutive patients who underwent coronary calcium scoring and coronary CT angiography before undergoing noncoronary cardiovascular surgery. Seven patients were excluded because of contraindications to CT angiography. The major indication of noncoronary cardiovascular surgery was valvular heart disease (121 patients). Follow-up was performed at a median of 20 months to define ischemic events described as acute coronary syndrome or death secondary to acute coronary syndrome, arrhythmias, or cardiac failure. Multivariate analysis was performed to determine predictors of nondiagnostic coronary CT angiography. Kaplan-Meier analysis was performed to evaluate outcome at follow-up. RESULTS: Twenty-one patients did not undergo surgery, which left 133 patients as the study group. Atrial fibrillation was present in 45 of 133 patients. The interquartile range of the Agatston coronary calcium score was 0-471. Coronary CT angiography was diagnostic in 108 of 133 patients. Of these, 93 of 108 had no significant CAD (≤ 50% stenosis), and noncoronary cardiovascular surgery was performed in them without preoperative ICA. No patients in this group had postoperative ischemic events at follow-up. Coronary CT angiography was nondiagnostic in 25 of 133 patients who were referred for preoperative ICA. Multivariate analysis showed Agatston score to be the only independent predictor of nondiagnostic coronary CT angiography (odds ratio = 1.002; 95% confidence interval: 1.001, 1.003; P = .001). The best Agatston score cutoff for diagnostic coronary CT angiography was 579. CONCLUSION: In nonselected patients scheduled to undergo noncoronary cardiovascular surgery, preoperative coronary CT angiography was diagnostic in 81% of cases. Preoperative ICA could be safely avoided in patients without significant CAD by using coronary CT angiography. The Agatston score, but not the presence of atrial fibrillation, was an independent predictor of nondiagnostic coronary CT angiography. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100384/-/DC1.

Differentiation of athlete's heart and hypertrophic cardiomyopathy by the fractal dimension of left ventricular trabeculae.

BACKGROUND: Differentiation between exercise induced adaptive myocardial hypertrophy (athlete's heart) and hypertrophic cardiomyopathy (HCM) is currently based on echocardiographic and cardiac magnetic resonance (CMR) criteria, but these may be insufficient in patients with subtle phenotype expression. This study aimed to assess whether left ventricular (LV) fractal pattern could permit to differentiate athlete's heart from HCM. METHODS: We recruited retrospectively 61 elite marathon runners, 67 patients with HCM, and 33 healthy subjects. A CMR study was performed in all subjects and the LV trabeculae fractal dimension (FD) was measured in end-diastolic frames of each short-axis cine sequence. For group comparison, the ratio of maximal myocardial wall thickness (mMWT)/indexed LV end-diastolic volume (LVED) was determined. RESULTS: As compared with athletes, patients with HCM had significantly (p < 0.001) greater FD in the LV basal (1.30 ± 0.07 vs. 1.23 ± 0.05) and apical (1.38 ± 0.06 vs. 1.30 ± 0.07) regions and in the whole heart (1.34 ± 0.05 vs. 1.27 ± 0.05). FD increased with age, left atrial area and indexed left ventricular mass (p < 0.05 for all) and correlated negatively with LV and RV end-diastolic volumes (p < 0.05 each). The addition of whole heart FD to the ratio of maximal myocardial wall thickness/indexed LVEDV lead to an improvement in the ability to discriminate HCM with a net reclassification index (NRI) of 71%. CONCLUSIONS: The FD regional distribution of the LV trabeculae differentiates patients with athlete's heart from patients with HCM. The addition of whole heart FD to the mMWT/indexed LVEDV ratio improves the predictive capacity of the model to differentiate both entities.

Design of the ß3-Adrenergic Agonist Treatment in Chronic Pulmonary Hypertension Secondary to Heart Failure Trial.

Combined pre-and post-capillary hypertension (CpcPH) is a relatively common complication of heart failure (HF) associated with a poor prognosis. Currently, there is no specific therapy approved for this entity. Recently, treatment with beta-3 adrenergic receptor (ß3AR) agonists was able to improve pulmonary hemodynamics and right ventricular (RV) performance in a translational, large animal model of chronic PH. The authors present the design of a phase II randomized clinical trial that tests the benefits of mirabegron (a clinically available ß3AR agonist) in patients with CpcPH due to HF. The effect of ß3AR treatment will be evaluated on pulmonary hemodynamics, as well as clinical, biochemical, and advanced cardiac imaging parameters. (Beta3 Agonist Treatment in Chronic Pulmonary Hypertension Secondary to Heart Failure [SPHERE-HF]; NCT02775539).

[Noninvasive coronary angiography using multidetector computed tomography in patients with suspected coronary artery disease and a non-diagnostic exercise treadmill test result]. / Coronariografía no invasiva mediante tomografía computarizada con multidetectores en pacientes con sospecha de enfermedad coronaria y ergometría no diagnóstica.

BACKGROUND AND OBJECTIVE: We aimed to establish the diagnostic and prognostic usefulness of noninvasive coronary angiography using multidetector computer tomography (MDCT) in patients with clinical suspicion of coronary artery disease (CAD) and a non-diagnostic exercise treadmill test result. PATIENTS AND METHOD: Retrospective analysis in 33 patients evaluating the incidence of revascularization and hospitalization due to myocardial infarction or angina, and death. RESULTS: There were obstructive lesions in 7 (21%), non-obstructive lesions in 18 (55%), absence of lesions in 6 (18%), and, finally, 2 patients (6%) had an MDCT deemed as non-evaluable. The follow-up was extended up to 21 (10) months. Events appeared in 5 (15%) patients: 4 myocardial revascularizations in the group with obstructive coronary stenosis, and 1 cardiovascular death in the group with non-obstructive coronary lesions. No events were recorded among those 6 patients without coronary lesions nor in those 2 with non-evaluable MDCT studies. CONCLUSIONS: Patients with suspected CAD and a non-diagnostic exercise test present with a high prevalence of CAD when studied by MDCT and have a high incidence of cardiovascular events. The severity of stenosis as assessed by MDCT relates to cardiovascular events during the follow-up.

MR imaging of ischemic heart disease.

When ischemic heart disease (IHD) is suspected or confirmed, the primary imaging modality is echocardiography. When appropriate, complementary examinations can be performed. These include stress perfusion scintigraphy, cardiac catheterization, coronary angiography, and CT. MR imaging techniques have developed rapidly over the past several years, and MR imaging has the ability to delineate myocardial perfusion, ventricular function, and myocardial viability in a single examination. Although coronary MR angiography is promising, in recent years it has been supplanted as a noninvasive imaging modality by coronary CT angiography. The other capabilities of MR imaging suggest that it will be performed more and more frequently for the assessment of IHD.

New electrocardiographic diagnostic criteria for the pathologic R waves in leads V1 and V2 of anatomically lateral myocardial infarction.

AIMS: To study the different QRS patterns in leads V1 and V2 in first inferior, lateral, and combined inferolateral myocardial infarction (MI) to recognize which are the ECG criteria that best define the presence of lesions isolated to the anatomically lateral wall of the left ventricle. METHODS AND RESULTS: We studied consecutive patients with first inferior (15), lateral (9), or inferolateral (21) MI with reference to contrast enhanced cardiac magnetic resonance (CE-CRM). We measured the R-wave amplitude and duration, the R/S ratio, and the T-wave amplitude and polarity in leads V1 and V2. The specificity of the V1 criteria for lateral MI, that is, R/S amplitude ratio 1 or greater and R duration 40 milliseconds or longer, is very high but its sensitivity is low. We defined 2 new criteria, R/S of 0.5 or greater and R amplitude in V1 greater than 3 mm, with each achieving a sensitivity of 73.3% and specificity of 93.3% for lateral/inferolateral MI location. CONCLUSIONS: (1) New ECG criteria for lateral MI (R/S ratio in V1 > or =0.5 and R amplitude in V1 >3 mm) present very high specificity and lower but very acceptable sensitivity for lateral MI. (2) New criteria based on R waves in V2 or T waves in V1 to V2 do not discriminate between inferior and lateral MI. (3) The classical criteria (R/S amplitude ratio > or =1 and R duration > or =40 ms in V1) attain very high specificity but much lower sensitivity than the new criteria.

Myocardial remodelling and tissue characterisation by cardiovascular magnetic resonance (CMR) in endurance athletes.

There is still some controversy about the benignity of structural changes observed in athlete's heart, especially regarding the observation of increased biomarkers and the presence of myocardial fibrosis (MF). AIM: Our purpose was to evaluate by cardiovascular magnetic resonance (CMR) the presence of diffuse as well as focal MF in a series of high-performance veteran endurance athletes. METHODS: Thirty-four veteran healthy male endurance athletes, still being in regular training, with more than 10 years of training underwent a CMR. A cardiopulmonary exercise test was also performed to assess their maximal physical performance. The control group consisted in 12 non-trained normal individuals. RESULTS: We found an increase in both, right and left ventricular (LV) volumes in the athlete's group when compared with controls. There was no increase in indexed LV myocardial mass despite of a significantly increased maximal myocardial wall thickness in comparison to controls. Native T1 values and extracellular volume (ECV) were normal in all cases. We did not find differences in native T1 values and ECV between both groups. In three athletes (9%), non-ischaemic late gadolinium enhancement (LGE) was observed. We did not find a correlation between total training volume and presence of LGE or with the ECV value. CONCLUSIONS: Our results show that the majority of veteran endurance athletes present with myocardial remodelling without MF as a physiological adaptive phenomenon. In the only three athletes with focal MF, the LGE pattern observed suggests an intercurrent event not related with the remodelling phenomenon.

Concordance of electrocardiographic patterns and healed myocardial infarction location detected by cardiovascular magnetic resonance.

Q-wave myocardial infarction (MI) location is generally based on a pathologic correlation first proposed >50 years ago. Despite the proved reliability of contrast-enhanced cardiovascular magnetic resonance (CE-CMR) imaging to detect and locate infarcted areas, no global study has been conducted with the aim of correlating the electrocardiographic (ECG) patterns of Q-wave MI with infarct location. We studied this correlation in 51 patients with ST-elevation acute coronary syndrome who presented with Q waves or equivalents during MI. Seven preestablished ECG patterns that matched with high specificity to 7 different MI locations as detected by CE-CMR imaging were used to assess its value in clinical practice to locate an infarcted area. There were 4 ECG patterns in the anteroseptal zone (23 patients; septal, apical, and/or anteroseptal, extensive anterior, and limited anterolateral) and 3 ECG patterns in the inferolateral zone (28 patients; lateral, inferior, and inferolateral). In conclusion, (1) the predefined ECG patterns we used matched well (86% global concordance) with their corresponding infarction areas as detected by CE-CMR imaging and have real value in clinical practice, and (2) the RS morphology in lead V(1) is due to lateral MI and the QS morphology in lead aVL is due to mid-anterior and mid-lateral MI. Therefore, the terms posterior and high lateral infarction are incorrect and should be changed to lateral wall and limited anterolateral wall MI.

Morphological and functional evidences of the helical heart from non-invasive cardiac imaging.

The non-invasive study of cardiac mechanics has been improved after the recent introduction of advanced magnetic resonance and echocardiographic imaging techniques. Tagged and diffusion-sensitive cardiac magnetic resonance allows the study of myocardial torsion dynamics as well as the anatomical disposition of myocardial fibers. Local myocardial strain and synchronicity of myocardial contraction can also be determined with Doppler tissue imaging (DTI) echocardiography. Published results with these techniques demonstrate a mechanical behavior that is a consequence of a myocardial helical fiber orientation and strongly support the evidence of the double-loop single muscular band model described by Torrent-Guasp.

Assessment of Inducible Myocardial Ischemia, Quality of Life, and Functional Status After Successful Percutaneous Revascularization in Patients With Chronic Total Coronary Occlusion.

The benefits of chronic total coronary occlusion (CTO) revascularization are not well established. In this prospective cohort study, 47 consecutive patients with successful percutaneous recanalization of CTO underwent adenosine stress cardiac magnetic resonance (CMR), 6-minute walk test (6MWT), and the Short Form-36 Health Survey before and 6 months after the procedure. Successful recanalization of a CTO was followed by significant improvement of (1) global physical and mental health status; (2) the distance walked in the 6MWT; (3) the incidence of chest pain at the end of the 6MWT; and (4) the score of a novel CMR ischemic burden index on the basis of the characteristics of adenosine stress perfusion defects (extension, persistence, transmurality, and induced contractile regional dysfunction). Patients with greater CMR ischemic index before percutaneous revascularization showed better improvement in the 6MWT. In conclusion, successful recanalization of a CTO leads to a concurrent improvement in ischemic burden, exercise tolerance, angina frequency, and quality of life scores. Patients with a high ischemic CMR score before CTO recanalization showed the better improvement in exercise tolerance.

One-Year Results of Bioresorbable Vascular Scaffolds for Coronary Chronic Total Occlusions.

The potential of bioresorbable vascular scaffold (BVS) technology has been demonstrated in first-in-man studies with up to 5-year follow-up. This study sought to investigate the 1-year outcomes of the BVS, for the treatment of chronic total occlusions (CTOs), using various imaging techniques. Thirty-five true CTO lesions treated with BVS were included in this prospective study. Scaffolds were deployed after mandatory predilation and intravascular ultrasound analysis. Optical coherence tomography was performed after BVS implantation and at 10 to 12 months. Multislice computed tomography was performed at baseline and at 6 to 8 months. Mean patient age was 61 ± 10 years. The most frequent vessel treated was the right coronary artery (46%). Lesions were classified as intermediate (49%) or difficult/very difficult (26%) according to the Japanese CTO complexity score. Predilation was performed in 100% of lesions, using cutting balloons in 71% of these. The total scaffold length implanted per lesion was of 52 ± 23 mm. All scaffolds were delivered and deployed successfully. Postdilation was undertaken in 63%. By multislice computed tomography at 6 months, we observed 2 cases of asymptomatic scaffold restenosis, subsequently confirmed by angiography. At 12 months, no scaffold thrombosis or major adverse cardiac events were reported. The optical coherence tomography at follow-up showed that 94% of struts were well apposed and covered (5% of uncovered struts and 1% of nonapposed struts), and only 0.6% of struts were nonapposed and uncovered. In conclusion, 1-year results suggest that BVS for CTO is associated with excellent clinical and imaging outcomes. Accurate percutaneous coronary BVS technique might have enabled these promising results.

[Morphologic study of the pulmonary veins by magnetic resonance angiography]. / Estudio morfológico de las venas pulmonares por angiorresonancia magnética.

Accurate knowledge of the anatomy of the pulmonary veins is important in clinical electrophysiology. In order to evaluate the usefulness of magnetic resonance angiography for this purpose, we studied 17 unselected patients. All the pulmonary veins were visualized in each individual. The diameters of the ostia ranged between 9 mm and 22 mm. The cross-section of the ostium was elliptical in 35% of cases. In 14 patients (82%), the 4 veins each had independent drainage. In 2 patients (12%), there was an additional intermediate right vein and, in 1 patient (6%), both left veins had a common ostium. In 74% of patients, the right pulmonary veins had a short common trunk with early branching. This pattern was seen in only 10% of left veins. Magnetic resonance angiography using a contrast medium is an excellent technique for studying the anatomy of the pulmonary veins and for identifying variants. The resulting information is potentially useful for electrophysiologists.

[Clinical value of cardiovascular magnetic resonance imaging in the diagnostic work-up of patients with suspected arrhythmogenic right ventricular dysplasia]. / Utilidad clínica de la cardiorresonancia magnética para el diagnóstico de pacientes con sospecha de displasia arritmogénica ventricular derecha.

INTRODUCTION AND OBJECTIVES: To analyze retrospectively the usefulness of cardiovascular magnetic resonance imaging in the assessment of patients with clinically suspected arrhythmogenic right ventricular dysplasia. MATERIAL AND METHOD: We reviewed retrospectively findings from 46 consecutive patients (mean age, 42+/-19 years; 25 male) who were referred for investigation to rule out right ventricular dysplasia. Abnormal findings were classified according to the general diagnostic criteria established by the European Society of Cardiology. RESULTS: Evaluable images were available for all patients. Abnormal right ventricular findings were reported in 24 patients (52%), but only 5 were given a definite diagnosis of right ventricular dysplasia. Fatty infiltration was observed in 9 patients; it was an isolated finding in 6 but was associated with right ventricular contractile dysfunction in 3. These latter patients belonged to the group with confirmed dysplasia. None of the 22 patients (48%) with normal findings on magnetic resonance imaging was given a diagnosis of dysplasia. CONCLUSIONS: Cardiovascular magnetic resonance imaging enabled the right ventricle to be assessed in all patients. In those with clinically suspected dysplasia, normal findings ruled out the diagnosis. However, only 21% of those with abnormal findings on magnetic resonance imaging were finally given a confirmed diagnosis of dysplasia. Fatty infiltration of the right ventricular wall does not imply dysplasia unless it is associated with other abnormalities in right ventricular morphology or contractility. Cardiovascular magnetic resonance imaging is useful in the work-up of patients with clinically suspected arrhythmogenic right ventricular dysplasia.

Bioresorbable everolimus-eluting vascular scaffold for the treatment of chronic total occlusions: CTO-ABSORB pilot study.

AIMS: We sought to assess the safety and performance of the Absorb everolimus-eluting bioresorbable vascular scaffold (BVS) in percutaneous chronic total occlusion (CTO) revascularisation guided by intracoronary imaging. The feasibility of using the BVS in CTO lesions is unknown. METHODS AND RESULTS: Thirty-five consecutive true CTO lesions (EuroCTO Club definition) were included in this prospective registry. After mandatory predilatation and IVUS analysis, all target lesions were treated with BVS and no other stents were deployed. Optical coherence tomography (OCT) was performed after BVS implantation. Multislice computed tomography (MSCT) was performed at baseline and at six to eight months. The mean age was 60.7±9.7 years; 80% were male; 20% were diabetic; 37% had a previous PCI. The most frequently treated vessel was the RCA (46%). According to the Japanese-CTO (J-CTO) complexity score, most lesions were classified as intermediate (49%) or difficult-very difficult (26%); 34% were moderate-severely calcified. Most cases (86%) were treated with an anterograde strategy, 60% by radial or biradial approach. In 71% a cutting balloon was used. The total scaffold length implanted per lesion was 52.5±22.9 mm. All scaffolds were successfully delivered and deployed. Post-dilatation was undertaken in 63%. By OCT, final minimum scaffold area and lumen stenosis were 7.1±1.5 mm2 and 11.7±6.6%, without areas of significant strut malapposition. At complete six-month follow-up, no major adverse events were observed. MSCT identified two cases of scaffold reocclusion. CONCLUSIONS: BVS for CTO recanalisation demonstrates excellent feasibility and safety as well as midterm efficacy. Appropriate lesion preparation is key to aiding adequate expansion of these scaffolds in this setting.

[Assessment of myocardial perfusion by cardiovascular magnetic resonance: comparison with coronary angiography]. / Estudio de perfusión miocárdica por cardiorresonancia magnética: comparación con la angiografía coronaria.

INTRODUCTION AND OBJECTIVES: The assessment of regional myocardial perfusion by cardiovascular magnetic resonance imaging makes it possible to detect significant coronary artery lesions. The purpose of this study was to determine the usefulness of this technique in non-selected patients with ischemic heart disease. PATIENTS AND METHOD: The study group included 32 patients (26 men; mean age: 65 years old). Gadolinium (0.05 mmol/kg) for first-pass imaging was administered through a peripheral vein, both at rest and after adenosine infusion (140 mg/kg for 6 min). The presence of a regional perfusion defect was assessed visually, and these images were compared against coronary angiographic images. RESULTS: Angiography showed 49 significant (> 70%) obstructive lesions in a coronary artery. Magnetic resonance showed a perfusion defect at rest (fixed) in 35 myocardial segments, and only after adenosine infusion (reversible) in 16 additional regions, for a total of 51 segments with perfusion defect. Sensitivity for the detection of an angiographically significant coronary lesion was 78%, with a specificity of 75%. These figures decreased to 54% and 65%, respectively, when only fixed defects were considered. There were no visible defects in 26% of the myocardial territories with proven previous necrosis, although effective reperfusion and patent culprit arteries were frequently seen in these cases. CONCLUSIONS: The detection of a regional myocardial perfusion defect by visual analysis with first-pass gadolinium and cardiovascular magnetic resonance imaging shows good diagnostic accuracy for the presence of significant coronary artery obstruction, provided that both rest and pharmacological stress studies are performed.

[Usefulness of hand-held echocardiography in emergency room]. / Utilidad de un equipo de ecocardiografía portátil en un servicio de urgencias generales.

BACKGROUND AND OBJECTIVE: Handheld echocardiography may be a powerful diagnostic tool in the emergency room. However, its usefulness in this environment when it is performed by medical personnel with a basic training in echocardiography remains to be clarified. PATIENTS AND METHOD: A cardiologist with expertise in echocardiography and a cardiology fellow with basic training evaluated 33 patients admitted in emergency using a handheld device. RESULTS: The echocardiogram led to a change in the diagnosis and treatment in 27% and 46% of patients, respectively, allowing an early discharge in 49% of cases. The agreement between the two observers was acceptable. CONCLUSIONS: Portable echocardiography is a useful tool in emergency rooms and may be reliably performed by medical personnel with basic training in echocardiography.

Improvement of myocardial function and perfusion after successful percutaneous revascularization in patients with chronic total coronary occlusion.

BACKGROUND: Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of a coronary artery can provide benefits in terms of myocardial function and survival but the procedure is complex and the success rate is relatively low. To assess these benefits, myocardial function, ischemia and viability should be clearly determined by means of a reliable diagnostic test. This study aimed to assess ventricular function and myocardial ischemia before and after PCI for CTO using cardiac magnetic resonance (CMR). NYHA functional class was also assessed before and after PCI. METHODS AND RESULTS: CMR studies were performed in 43 consecutive patients (7 females; aged 64 ± 9.6 y.o.) with CTO scheduled for PCI and repeated 6 months post-PCI. PCI was successful in 33 (77%) of them. In this group CMR had shown inducible perfusion defects in 26 (79%) before PCI, while they were observed in 10 (30%) post-PCI CMR study (p < 0.001). The number of segments showing inducible perfusion defect (3.4 ± 2 prevs. 2.9 ± 4.5 post-PCI, p = 0.002) was significantly reduced in this group. Regional contractile function of segments showing viability also improved significantly in the group with successful CTO PCI compared to the group with an unsuccessful procedure. NYHA functional class for angina also improved in patients with successful revascularization while it remained unchanged in the group with unsuccessful procedures. CONCLUSIONS: A successful CTO PCI leads to a reduction in inducible myocardial ischemia and to an improvement in regional wall motion, which results in clinical improvement.