Resolution of Cardiac Infiltration Following Autologous Stem Cell Transplantation for AL Amyloidosis.

A 43-year-old man presented with severe heart failure secondary to high-risk light chain cardiac amyloidosis. He underwent chemotherapy and autologous stem cell transplantation with complete hematologic response. Serial cardiac magnetic resonance imaging post-transplant demonstrated gradual normalization of biventricular function and myocardial T1, a surrogate measure of disease burden.

Sex differences in post-operative outcomes following non-cardiac surgery.

It is uncertain whether sex is an independent risk factor for poor outcomes after non-cardiac surgery. We examined sex differences in short- and long-term mortality and morbidity in patients undergoing non-cardiac surgery in Alberta, Canada. Using linked administrative databases, we identified patients undergoing one of 45 different non-cardiac surgeries who were hospitalized between 2008 and 2019. Adjusted odds ratios (95% CI) were reported for mortality at 30-days, 6-months, and 1-year stratified by sex. Secondary outcomes including all-cause hospitalization, hospitalization for heart failure (HF), hospitalization for acute coronary syndrome (ACS), hospitalization for infection, hospitalization for stroke, and hospitalization for bleeding were also analyzed. Multivariate logistic regression was adjusted for age, sex, surgery type, the components of the Charlson Comorbidity Index, and the Revised Cardiac Risk Index. We identified 552,224 unique patients who underwent non-cardiac surgery of which 304,408 (55.1%) were female. Male sex was a predictor of mortality at 30-days (aOR 1.25 (1.14, 1.38), p<0.0001), 6-months (aOR 1.26 (1.20, 1.33), p<0.0001), and 1-year (aOR 1.25 (1.20, 1.31), p<0.0001). Similarly, male sex was a predictor of hospital readmission at 30-days (1.12 (1.09, 1.14), p<0.0001), 6-months (aOR 1.11 (1.10, 1.13), p<0.0001), and 1-year (aOR 1.06 (1.04, 1.07), p<0.0001). When the results were stratified by age, the effect of male sex on clinical outcome diminished for age ≥ 65years compared to younger patients. In conclusion, male patients undergoing non-cardiac surgery have higher risks of all-cause mortality and readmission after adjustment for baseline risk factor differences, particularly in those under 65-years-old. The overall incidence of readmission for stroke, bleeding, HF and ACS after non-cardiac surgery was low. The impact of male sex on clinical outcomes decreases with increasing age, suggesting the importance of considering the effect of both sex and age on clinical outcomes after non-cardiac surgery.

Does cardiac imaging surveillance strategy influence outcomes in patients with early breast cancer?

Background: Many patients with breast cancer receive therapies with the potential to cause cardiotoxicity. Echocardiography and multiple-gated acquisition (MUGA) scans are the most used modalities to assess cardiac function during treatment in high-risk patients; however, the optimal imaging strategy and the impact on outcome are unknown. Methods: Consecutive patients with stage 0-3 breast cancer undergoing pre-treatment echocardiography or MUGA were identified from a tertiary care cancer center from 2010-2019. Demographics, medical history, imaging data and clinical events were collected from hospital charts and administrative databases. The primary outcome is a composite of all-cause death or heart failure event. Clinical and imaging predictors of outcome were evaluated on univariable and multivariable analyses. Results: 1028 patients underwent pre-treatment MUGA and 1032 underwent echocardiography. The groups were well matched for most clinical characteristics except patients undergoing MUGA were younger, had more stage 3 breast cancer and more HER2 over-expressing and triple negative cases. Routine follow-up cardiac imaging scan was obtained in 39.3% of patients with MUGA and 38.0% with echocardiography. During a median follow-up of 2448 (1489, 3160) days, there were 194 deaths, including 7 cardiovascular deaths, and 28 heart failure events with no difference in events between the MUGA and echocardiography groups. There were no imaging predictors of the primary composite outcome or cardiac events. Patients without follow-up imaging had similar adjusted risk for the composite outcome compared to those with imaging follow-up, hazard ratio 0.8 (95% confidence interval 0.5,1.3), p=0.457. Conclusion: The selection of pretreatment echocardiography or MUGA did not influence the risk of death or heart failure in patients with early breast cancer. Many patients did not have any follow-up cardiac imaging and did not suffer worse outcomes. Cardiovascular deaths and heart failure event rates were low and the value of long-term cardiac imaging surveillance should be further evaluated.

An Unusual Case of Obstructive Shock.

A 54-year-old man presented in profound obstructive shock. Investigations revealed a right atrial mass causing severe right ventricular inflow obstruction and compromised cardiac output. The patient was treated with emergency balloon catheter intervention to relieve the obstruction, with resulting hemodynamic stability. The pathology report later returned a positive result for diffuse large B-cell lymphoma. (Level of Difficulty: Intermediate.).

Reproducible Quantification of Regional Sympathetic Denervation with [11C]meta-Hydroxyephedrine PET Imaging.

BACKGROUND: Regional cardiac sympathetic denervation is predictive of sudden cardiac arrest in patients with ischemic cardiomyopathy. The reproducibility of denervation scores between automated software programs has not been evaluated. This study seeks to (1) compare the inter-rater reliability of regional denervation measurements using two analysis programs: FlowQuant® and Corridor4DM®; (2) evaluate test-retest repeatability of regional denervation scores. METHODS: N = 190 dynamic [11C]meta-hydroxyephedrine (HED) PET scans were reviewed from the PAREPET trial in ischemic cardiomyopathy patients with reduced left ventricular ejection fraction(LVEF ≤ 35%). N = 12 scans were excluded due to non-diagnostic quality. N = 178 scans were analyzed using FlowQuant and Corridor4DM software, each by two observers. Test-retest scans from N = 20 patients with stable heart failure were utilized for test-retest analysis. Denervation scores were defined as extent × severity of relative uptake defects in LV regions with < 75% of maximal uptake. Results were evaluated using intraclass correlation coefficient (ICC) and Bland-Altman coefficient of repeatability (RPC). RESULTS: Inter-observer, inter-software, and test-retest ICC values were excellent (ICC = 94% to 99%) and measurement variability was small (RPC < 11%). Mean differences between observers ranged .2% to 1.1% for Corridor4DM (P = .28), FlowQuant (P < .001), and between software programs (P < .001). Kaplan-Meier analysis demonstrated HED scores from both programs were predictive of SCA. CONCLUSION: Inter-rater reliability for both analysis programs was excellent and test-retest repeatability was consistent. The minimal difference in scores between FlowQuant and Corridor4DM supports their use in future trials.

Saline-push improves rubidium-82 PET image quality.

INTRODUCTION: Rubidium-82 (82Rb) PET is used widely for myocardial perfusion imaging. The purpose of this study was to investigate if an additional saline-push following the 82Rb elution improves PET image quality. METHODS: 82Rb PET scans were acquired with and without 26 mL saline-push in six patients as part of a clinical quality improvement program. Dynamic images were analyzed to measure the total activity delivered to the superior vena cava (SVC) and retained in the left ventricle (LV) myocardium. Tracer uptake images were used to measure blood background coefficient-of-variation (COV), myocardium-to-blood signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) to assess image quality. RESULTS: Similar eluted activity was measured with/without the saline-push (830 vs 795 MBq; P = 0.24). The activity delivered to the heart and retained in the myocardium was consistently increased more than twofold (SVC: + 114% and LV: + 104%; P < 0.001) with the saline-push. Image quality was improved in all patients, with lower background noise (COV: - 19%), higher SNR (+ 24%) and CNR (+ 27%) (all P ≤ 0.01). CONCLUSIONS: The saline-push used to flush 82Rb activity out of the infuser tubing, patient injection and intravenous access lines consistently increased the activity delivered to the heart by twofold. This technique is recommended to maximize image quality with 82Rb PET.

Is Immigrant Status Associated With Cervical Cancer Screening Among Women in Canada? Results From a Cross-Sectional Study.

OBJECTIVE: Cervical cancer accounts for the highest mortality rate from cancer in women worldwide. Despite widespread availability of cervical cancer screening programs in Canada, immigrant women are largely underscreened. The most recently published Canadian-wide study evaluated screening uptake from 2001 to 2002. The objectives included identifying the prevalence of underscreened women in Canada, determining the risk of underscreening for cervical cancer among immigrant women, and providing an update on Canadian screening practices. METHODS: This study included women aged 20 to 69 who completed the Canadian Community Health Survey 2012. The prevalence of underscreening among Canadian-born and immigrant women was estimated. A log-binomial model was fit to estimate the relative risk (RR) of underscreening for immigrant women while controlling for age, income level, visible minority status, smoking status, and access to a regular physician. A secondary analysis compared immigrants residing in Canada for greater or less than 10 years to Canadian-born women. RESULTS: Of the 17 854 women eligible for this study, 18.6% of Canadian-born women and 28.9% of immigrant women were underscreened (P < 0.05). Immigrant women were at significantly higher risk of being underscreened compared with Canadian-born women (RR 1.32; 95% CI 1.20-1.45). The relative risk did not change when stratifying by length of time since immigration (RRrecent immigrant 1.32; 95% CI 1.16-1.50; and RRlong-term immigrant 1.32; 95% CI 1.19-1.47). CONCLUSION: Immigrant status continues to be associated with a significantly higher risk of underscreening, irrespective of time in Canada. Social and educational programs targeted towards immigrants are needed to mitigate the disparity in cervical cancer screening.