Exercise Stress Test Late after Arrhythmic versus Nonarrhythmic Presentation of Myocarditis.

Background. Exercise stress test (EST) has been scarcely investigated in patients with arrhythmic myocarditis. Objectives. To report the results of EST late after myocarditis with arrhythmic vs. nonarrhythmic presentation. Methods. We enrolled consecutive adult patients with EST performed at least six months after acute myocarditis was diagnosed using gold-standard techniques. Patients with ventricular arrhythmia (VA) at presentation were compared with the nonarrhythmic group. Adverse events occurring during follow-up after EST included cardiac death, disease-related rehospitalization, malignant VA, and proven active myocarditis. Results. The study cohort was composed of 128 patients (age 41 ± 9 y, 70% males) undergoing EST after myocarditis. Of them, 64 (50%) had arrhythmic presentation. EST was performed after 15 ± 4 months from initial diagnosis, and was conducted on betablockers in 75 cases (59%). During EST, VA were more common in the arrhythmic group (43 vs. 4, p < 0.001), whereas signs and symptoms of ischemia were more prevalent in the nonarrhythmic one (6 vs. 1, p = 0.115). By 58-month mean follow-up, 52 patients (41%) experienced adverse events, with a greater prevalence among arrhythmic patients (39 vs. 13, p < 0.001). As documented both in the arrhythmic and nonarrhythmic subgroups, patients had greater prevalence of adverse events following a positive EST (40/54 vs. 12/74 with negative EST, p < 0.001). Electrocardiographic features of VA during EST correlated with the subsequent inflammatory restaging of myocarditis. Nonarrhythmic patients with uneventful EST both on- and off-treatment were free from subsequent adverse events. Conclusions. Late after the arrhythmic presentation of myocarditis, EST was frequently associated with recurrent VA. In both arrhythmic and nonarrhythmic myocarditis, EST abnormalities correlated with subsequent adverse outcomes.

Myocardial Late Contrast Enhancement CT in Troponin-Positive Acute Chest Pain Syndrome.

Background Acute chest pain with mild troponin rise and inconclusive diagnosis after clinical evaluation represents a diagnostic challenge. Triple-rule-out (TRO) CT may exclude coronary artery disease (CAD), as well as acute aortic syndrome and pulmonary embolism, but cannot help identify other causes of myocardial injury. Purpose To investigate the diagnostic value of a comprehensive CT protocol including both an angiographic and a late contrast enhancement (LCE) scan in participants with troponin-positive acute chest pain. Materials and Methods In this prospective study, consecutive patients with troponin-positive acute chest pain or anginal equivalent and inconclusive diagnosis after clinical evaluation (symptoms, markers, electrocardiography, and echocardiography) who underwent TRO CT between June 2018 and September 2020 were enrolled. TRO CT was performed to evaluate the presence of obstructive CAD (stenosis ≥50%), acute aortic syndrome, and pulmonary embolism. If the findings on the TRO CT scan were negative, an LCE CT scan was acquired after 10 minutes to assess the presence and pattern of scar and quantify the myocardial extracellular volume fraction. CT-based diagnoses were compared with diagnoses obtained with reference standard methods, including invasive coronary angiography, cardiac MRI, and endomyocardial biopsy. Results Eighty-four patients (median age, 69 years [interquartile range, 50-77 years]; 45 men) were enrolled. TRO CT helped identify obstructive CAD in 35 participants (42%), acute aortic syndrome in one (1.2%), and pulmonary embolism in six (7.1%). LCE CT scans were acquired in the remaining 42 participants. The following diagnoses were reached with use of LCE CT: myocarditis (22 of 42 participants [52%]), takotsubo cardiomyopathy (four of 42 [10%]), amyloidosis (three of 42 [7.1%]), myocardial infarction with nonobstructed coronary arteries (three of 42 [7.1%]), dilated cardiomyopathy (two of 42 [4.8%]), and negative or inconclusive findings (eight of 42 [19%]). The addition of LCE CT improved the diagnostic rate of TRO CT from 42 of 84 participants (50% [95% CI: 38.9, 61.1]) to 76 of 84 (90% [95% CI: 82.1, 95.8]) (P < .001). Conclusion A CT protocol including triple-rule-out and late contrast enhancement CT scans improved diagnostic rate in participants presenting with acute chest pain syndrome. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Nagpal and Bluemke in this issue.

Right ventricular endomyocardial biopsy in patients with cardiac magnetic resonance showing left ventricular myocarditis.

AIMS: The aim of this study was to evaluate the sensitivity of right ventricular endomyocardial biopsy (EMB) in myocarditis patients with cardiac magnetic resonance (CMR) and electroanatomical mapping (EAM) showing left ventricular abnormalities. METHODS: We performed right ventricular EMB in 144 consecutive patients (66% men, age 43 ±â€Š15 years) with acute symptoms and CMR-proved diagnosis of left ventricular myocarditis. Right ventricular EMB sensitivity has been evaluated in patients with different localization and extension of abnormal substrate at both CMR and -- when performed -- EAM. Abnormal substrate was defined, respectively, by late gadolinium enhancement (LGE) and low-voltage areas (LVAs). RESULTS: Globally, right ventricular EMB sensitivity was 87.5%. EMB-negative cases had significantly smaller fragment sizes (cumulative area 2.8 ±â€Š1.7 vs. 3.8 ±â€Š1.8 mm2, P = 0.023), and lower LGE surface extension (24.7 ±â€Š14.2 vs. 38.5 ±â€Š20.2%, P = 0.006) and transmurality (32.0 ±â€Š26.1 vs. 49.3 ±â€Š22.6, P = 0.003). Right ventricular EMB sensitivity in patients with LGE involving both right ventricular and interventricular septum (IVS), isolated right ventricular or IVS, and remote left ventricular areas (n = 10, 49 and 67 cases) was 83.3, 84.4 and 90.5%, respectively (P = 0.522). Overall, 34 patients (23.6%) underwent EAM. On the basis of EAM, right ventricular EMB sensitivity was 85.3%: in detail, it was 50.0, 88.2 and 86.7% in patients with both right ventricular and IVS, isolated right ventricular/IVS and distant left ventricular involvement (n = 2, 17 and 15, respectively, P > 0.05). Sample size area was the only factor associated with right ventricular EMB sensitivity (hazard ratio = 1.6/mm2, 95% confidence interval 1.1-2.4, P = 0.013). CONCLUSION: Right ventricular EMB is still an accurate technique to confirm diagnosis in patients with CMR-proved left ventricular myocarditis. In particular, provided there is an adequate sample size, its sensitivity is comparable among patients with heterogeneous LGE or LVA localization.

Immunosuppressive therapy in childhood-onset arrhythmogenic inflammatory cardiomyopathy.

We present, to our knowledge, the first case of immunosuppressive therapy (IST) application in a 12-year-old child with arrhythmogenic inflammatory cardiomyopathy resulting from the overlap between autoimmune myocarditis and primary arrhythmogenic cardiomyopathy. Indication to off-lable IST was compelling, because of recurrent drug-refractory ventricular arrhythmias (VAs). We show that IST was feasible, safe, and effective on multiple clinical endpoints, including symptoms, VA recurrences, and T-troponin release. Remarkably, all diagnostic and therapeutic strategies were worked out by a dedicated multidisciplinary team, including specialized pediatric immunologists.

Contrast-Induced Nephropathy After Percutaneous Coronary Intervention for Chronic Total Occlusion Versus Non-Occlusive Coronary Artery Disease.

Contrast volume is associated with the incidence of contrast-induced nephropathy (CIN), and CIN risk could be particularly high in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Our aim was to evaluate the incidence of CIN in patients who underwent CTO versus non-CTO PCI. All PCIs performed at our institution from January 2012 to December 2016 were included in this study. CIN was defined as an increase of ≥0.3 mg/dl or ≥50% from baseline within 72 hours. Multivariable logistic regression analysis was performed to identify independent predictors of CIN. A total of 2,580 patients were included (n = 309 CTO PCI and n = 2271 non-CTO PCI). Estimated glomerular filtration rate was lower in the non-CTO group (73.9 ± 27.3 vs 77.1 ± 24.7 ml/min/1.73/m2, p = 0.05). Patients in the non-CTO PCI group presented more often with acute coronary syndrome (47% vs 15%, p < 0.001). Contrast volume (347 ± 159 vs 215 ± 107 ml, p < 0.001) and contrast-volume-to-creatinine-clearance ratio (4.7 ± 2.1 vs 3.2 ± 1.8, p < 0.001) were higher in the CTO group. There was no difference in CIN rates between CTO and non-CTO groups (9.4% vs 12.1%, p = 0.17). This was confirmed in a sensitivity analysis including only patients who underwent PCI in a stable clinical setting (7.7% vs 8.5%, p = 0.66). On multivariate analysis hypotension during/before PCI (odds ratio [OR] 2.86), acute coronary syndrome (OR 1.86), age (OR 1.54), female sex (OR 1.51), left ventricular ejection fraction (OR 0.64), diabetes mellitus (OR 1.49), and contrast volume (OR 1.17) were independent predictors of CIN, while CTO PCI was not. In conclusion, CTO PCI is associated with similar rates of CIN, compared with non-CTO PCI. These findings persisted on sensitivity and multivariable analyses.

Usefulness of contrast-enhanced transoesophageal echocardiography to guide thoracic endovascular aortic repair procedure.

AIMS: Thoracic endovascular aortic repair (TEVAR) is commonly considered as a valid alternative to surgery. Endoleaks occurrence is one of the principal limitations of TEVAR. Transoesophageal echocardiography (TEE) is often adopted in adjunct to fluoroscopy and angiography (ANGIO) during stent-graft implantation. In the present study, we compare intraprocedural ANGIO, TEE, and contrast-enhanced TEE (cTEE), and we also evaluate their accuracy in early endoleaks detection and characterization. METHODS AND RESULTS: Fifty-four patients with thoracic aortic disease suitable for TEVAR were prospectively enrolled in the study. After stent placement, the result of the procedure was assessed by ANGIO, TEE, and cTEE. The use of contrast (Sonovue, Bracco) significantly improved TEE quality (P = 0.0001). cTEE was superior in entry tears, false and true lumen and aneurysm thrombosis identification, and microtears and ulcer-like projections detection before stent deployment. After stent deployment, cTEE was more accurate than TEE and ANGIO in the detection of slow flow in the false lumen and in the aneurismal sac (P = 0.0001), and in the remaining flow identification (P = 0.0001). Notably, cTEE is more accurate in the endoleaks detection (P = 0.0001) and in the incomplete stent expansion diagnosis and need for a further balloon inflation (P 0.002), or a further stent implantation (P 0.006), compared with TEE and ANGIO. CONCLUSION: TEVAR procedures are improved by the complimentary use of contrast fluoroscopy, multiplane TEE with Doppler flow interrogation, and cTEE. This triple imaging approach provides additional information in all phases of the procedure improving safety of stent-grafting and the procedural outcomes.

Acute pulmonary edema caused by a giant atrial myxoma.

Atrial myxoma is the most common primary cardiac tumor. Its clinical presentation spreads from asymptomatic incidental mass to serious life-threatening cardiovascular complications. We report the case of a 44-year-old man with evening fever and worsening dyspnea in the last weeks, admitted to our hospital for acute pulmonary edema. The cardiac auscultation was very suspicious for mitral valve stenosis, but the echocardiography revealed a huge atrial mass with a diastolic prolapse into mitral valve orifice causing an extremely high transmitral gradient pressure. Awareness of this uncommon acute presentation of atrial myxoma is necessary for timely diagnosis and prompt surgical intervention.

Electrocardiographic Q-wave "remodeling" in reperfused ST-segment elevation myocardial infarction: validation study with CMR.

OBJECTIVES: The aim of this study was to evaluate the evolution in Q-wave expression during the first 5 years after a primary, successfully reperfused ST-segment elevation myocardial infarction (MI), using cardiac magnetic resonance (CMR) for infarct location, and to depict changes in infarct size and left ventricular remodeling over time. BACKGROUND: In the absence of QRS confounders, abnormal Q waves are usually diagnostic of myocardial necrosis. It is hypothesized that Q-wave regression after MI could be related to smaller infarct sizes. Late gadolinium enhancement accurately depicts MI of any age. METHODS: Forty-six MI patients underwent electrocardiography and CMR at 1 week (baseline), 4 months, 1 year, and 5 years post-infarction. Conventional CMR parameters were analyzed, and infarct presence, location, and size were assessed using late gadolinium enhancement CMR. Infarct locations were anterior or nonanterior (inferior and/or lateral), using late gadolinium enhancement CMR as a reference. For each time point, patients were classified as having a diagnostic/nondiagnostic electrocardiogram (ECG) using the European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation consensus criteria for previous Q-wave infarct. RESULTS: At baseline, 11 patients (23%) did not meet the criteria for Q-wave MI. Non-Q-wave infarcts were significantly smaller than Q-wave infarcts (p < 0.0001). All anterior Q-wave infarcts (n = 17) were correctly localized, whereas in 7 of 19 nonanterior Q-wave infarcts, the location or extent of the infarct was misjudged by electrocardiography. At 4-month/1-year follow-up, in 10 patients (3 anterior/7 nonanterior), the ECG became nondiagnostic. The ECG remained nondiagnostic at 5-year follow-up. A cutoff infarct size of 6.2% at 1 year yielded a sensitivity of 89% and a specificity of 74% to predict the presence or absence of Q waves. CONCLUSIONS: The incidence of nondiagnostic ECGs for previous MI using the current European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation criteria is substantial and increases with time post-infarction from 23% immediately post-infarction to 44% at 5-year follow-up.

Successful treatment of polymicrobial multivalve infective endocarditis. Multivalve infective endocarditis.

A 57-year-old man presented with triple valve infective endocarditis. There were vegetations on the tricuspid, mitral, and aortic valve. He had multiple complications such as pulmonary abscess, severe anaemia, and congestive heart failure. His general condition was extremely poor. Intensive medical therapy, such as blood transfusion, mechanical ventilation, and inotropic support, allowed him to tolerate surgery. Triple valve replacement was successfully performed without major complication. Vegetation cultures grew Streptococcus bovis and Enterecoccus faecalis. At 1 year follow-up, the patient is alive in NYHA functional class I.