Randomized Pilot Clinical Trial of Early Coronary Angiography Versus No Early Coronary Angiography After Cardiac Arrest Without ST-Segment Elevation: The PEARL Study.

BACKGROUND: The benefit of emergency coronary angiography after resuscitation from out-of-hospital cardiac arrest is uncertain for patients without ST-segment elevation. The aim of this randomized trial was to evaluate the efficacy and safety of early coronary angiography and to determine the prevalence of acute coronary occlusion in resuscitated patients with out-of-hospital cardiac arrest without ST-segment elevation. METHODS: Adult (>18 years) comatose survivors without ST-segment elevation after resuscitation from out-of-hospital cardiac arrest were prospectively randomized in a 1:1 fashion under exception to informed consent regulations to early coronary angiography versus no early coronary angiography in this multicenter study. Early angiography was defined as ≤120 minutes from arrival at the percutaneous coronary intervention-capable facility. The primary end point was a composite of efficacy and safety measures, including efficacy measures of survival to discharge, favorable neurologic status at discharge (Cerebral Performance Category score ≤2), echocardiographic measures of left ventricular ejection fraction >50%, and a normal regional wall motion score of 16 within 24 hours of admission. Adverse events included rearrest, pulmonary edema on chest x-ray, acute renal dysfunction, bleeding requiring transfusion or intervention, hypotension (systolic arterial pressure ≤90 mm Hg), and pneumonia. Secondary end points included the incidence of culprit vessels with acute occlusion. RESULTS: The study was terminated prematurely before enrolling the target number of patients. A total of 99 patients were enrolled from 2015 to 2018, including 75 with initially shockable rhythms. Forty-nine patients were randomized to early coronary angiography. The primary end point of efficacy and safety was not different between the 2 groups (55.1% versus 46.0%; P=0.64). Early coronary angiography was not associated with any significant increase in survival (55.1% versus 48.0%; P=0.55) or adverse events (26.5% versus 26.0%; P=1.00). Early coronary angiography revealed a culprit vessel in 47%, with a total of 14% of patients undergoing early coronary angiography having an acutely occluded culprit coronary artery. CONCLUSIONS: This underpowered study, when considered together with previous clinical trials, does not support early coronary angiography for comatose survivors of cardiac arrest without ST elevation. Whether early detection of occluded potential culprit arteries leads to interventions that improve outcomes requires additional study. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02387398.

Imaging in heart failure with preserved ejection fraction: insights into echocardiography and cardiac magnetic resonance imaging.

Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent and represents more than half of all heart failure cases. It is defined by the presence of heart failure signs and symptoms, identification of cardiac structural abnormalities leading to high left ventricular filling pressures, and an EF > 50%. Common imaging findings in HFpEF include left ventricular hypertrophy, diastolic dysfunction, left atrial enlargement, and elevated pulmonary artery pressure (> 35 mm Hg). Echocardiography is the primary imaging modality for diagnosing HFpEF. It can be complemented by cardiac magnetic resonance (CMR) when further characterization is needed. Advances like real-time 3-dimensional echocardiography and speckle-tracking derived strain, as well as tissue characterization by CMR, have furthered our understanding of the mechanisms and aided in making the diagnosis of a diverse group of conditions that can present as HFpEF. This review aims to touch upon the imaging methods of characterizing HFpEF and discuss their role in specific disease entities.

Cardiac rehabilitation using telemedicine: the need for tele cardiac rehabilitation.

Cardiac Rehabilitation programs have shown to improve outcomes. The COVID-19 pandemic has posed barriers to these programs. A virtual platform might be a good solution to these challenges. Tele Cardiac Rehabilitation and remote patient monitoring provide an excellent alternative practical solution.

A multi-band double-inversion radial fast spin-echo technique for T2 cardiovascular magnetic resonance mapping of the heart.

BACKGROUND: Double inversion recovery (DIR) fast spin-echo (FSE) cardiovascular magnetic resonance (CMR) sequences are used clinically for black-blood T2-weighted imaging. However, these sequences suffer from slice inefficiency due to the non-selective inversion pulses. We propose a multi-band (MB) encoded DIR radial FSE (MB-DIR-RADFSE) technique to simultaneously excite two slices. This sequence has improved signal-to-noise ratio per unit time compared to a single slice excitation. It is also motion robust and enables the reconstruction of high-resolution black-blood T2-weighted images and T2 maps for the excited slices. METHODS: Hadamard encoded MB pulses were used in MB-DIR-RADFSE to simultaneously excite two slices. A principal component based iterative reconstruction was used to jointly reconstruct black-blood T2-weighted images and T2 maps. Phantom and in vivo experiments were performed to evaluate T2 mapping performance and results were compared to a T2-prepared balanced steady state free precession (bSSFP) method. The inter-segment variability of the T2 maps were assessed using data acquired on healthy subjects. A reproducibility study was performed to evaluate reproducibility of the proposed technique. RESULTS: Phantom experiments show that the T2 values estimated from MB-DIR-RADFSE are comparable to the spin-echo based reference, while T2-prepared bSSFP over-estimated T2 values. The relative contrast of the black-blood images from the multi-band scheme was comparable to those from a single slice acquisition. The myocardial segment analysis on 8 healthy subjects indicated a significant difference (p-value < 0.01) in the T2 estimates from the apical slice when compared to the mid-ventricular slice. The mean T2 estimate from 12 subjects obtained using T2-prepared bSSFP was significantly higher (p-value = 0.012) compared to MB-DIR-RADFSE, consistent with the phantom results. The Bland-Altman analysis showed excellent reproducibility between the MB-DIR-RADFSE measurements, with a mean T2 difference of 0.12 ms and coefficient of reproducibility of 2.07 in 15 clinical subjects. The utility of this technique is demonstrated in two subjects where the T2 maps show elevated values in regions of pathology. CONCLUSIONS: The use of multi-band pulses for excitation improves the slice efficiency of the double inversion fast spin-echo pulse sequence. The use of a radial trajectory and a joint reconstruction framework allows reconstruction of TE images and T2 maps for the excited slices.

Advantages and disadvantages of using intravenous tissue Plasminogen activator as salvage therapy for inoperable HeartWare thrombosis.

Device thrombosis is a devastating complication of left ventricular assist devices. The definitive treatment has been device exchange or explant. Evidence of increasing morbidity and mortality with device exchange has shifted strategies toward conservative management. In this report, we detail the use of thrombolytics as salvage therapy in a patient with an occlusive HeartWare ventricular assist device (HeartWare Inc., Framingham, MA) thrombus, resulting in long-term survival without further intervention.

Mitral valve replacement complicated by iatrogenic left ventricular outflow obstruction and paravalvular leak: case report and review of literature.

BACKGROUND: Left ventricular outflow tract (LVOT) obstruction and paravalvular leak (PVL) are relatively uncommon, but are serious complications of prosthetic valve replacement. CASE PRESENTATION: We present a case that displays the unique therapeutic challenges of treating a patient who developed both LVOT obstruction and mitral PVL after undergoing surgical aortic and mitral valve replacement (MVR). We also describe the use of alcohol septal ablation and albumin-glutaraldehyde (BioGlue) for septal ablation to percutaneously treat the patient's LVOT obstruction, followed by use of an Amplatzer vascular plug for percutaneous closure of an antero-medial mitral PVL associated with severe regurgitation. CONCLUSION: Percutaneous interventional management of these entities may be considered as an initial therapeutic option, especially in high-risk patients with significant morbidity and mortality of repeat surgical operations.

Hypertension as a risk factor for heart failure.

Hypertension remains a significant risk factor for development of congestive heart failure CHF), with various mechanisms contributing to both systolic and diastolic dysfunction. The pathogenesis of myocardial changes includes structural remodeling, left ventricular hypertrophy, and fibrosis. Activation of the sympathetic nervous system and renin-angiotensin system is a key contributing factor of hypertension, and thus interventions that antagonize these systems promote regression of hypertrophy and heart failure. Control of blood pressure is of paramount importance in improving the prognosis of patients with heart failure.

Comparison of methods for determining the partition coefficient of gadolinium in the myocardium using T1 mapping.

PURPOSE: To develop and validate modified Look-Locker (MOLLI) protocols to generate myocardial T1 maps within clinically acceptable breath-hold durations and to compare partition coefficients (λ) of gadolinium (Gd)-DTPA determined from either bolus injection (BI) or continuous infusion (CI) techniques. MATERIALS AND METHODS: T1 mapping was performed in phantoms and in 10 volunteers on a 1.5T scanner using the standard (3-3-5) MOLLI technique and two MOLLI schemes with shorter breath-hold durations. Imaging was performed precontrast and every 5 minutes following a bolus of 0.1 mmol/kg Gd-DTPA and a 15-minute delayed continuous infusion of 0.001 mmol/kg Gd-DTPA until equilibrium T1 in the myocardium was achieved to enable direct comparison of T1 relaxation times between techniques and λ's between the BI and CI methods. RESULTS: There was good agreement of T1 values between the 3-3-5 standard MOLLI protocol and the modified 3-5 MOLLI protocol in both phantom studies over a range of heart rates and in human subjects. Both MOLLI protocols produced similar measurements of λ using both the BI and CI methods. CONCLUSION: A reduced breath-hold MOLLI T1 mapping protocol combined with the BI method can accurately characterize T1 and λ in clinically applicable breath-hold durations without requiring a long equilibrium phase infusion.

Radionuclide imaging in stage B heart failure.

This article discusses currently available radionuclide techniques in the diagnostic and prognostic evaluation of patients with chronic heart failure, with a focus on stage B/asymptomatic left ventricular dysfunction. Radionuclide imaging is promising for such patients because it can simultaneously determine left ventricular function, evaluate for the presence of obstructive coronary disease, determine the extent of viable myocardium, and evaluate dyssynchronous left ventricular contraction. Radionuclide imaging can thus provide important noninvasive insights into the pathophysiology, prognosis, and management of patients with asymptomatic left ventricular dysfunction as well as more advanced heat failure.

Bioprosthetic aortic valve haemodynamic deterioration secondary to a thrombus.

A 77-year-old man with a history of coronary artery bypass grafting and surgical aortic valve replacement for severe aortic stenosis 2 years prior presented with exertional chest pain and shortness of breath. The patient underwent a thorough initial evaluation including a transthoracic echocardiogram and coronary angiogram without significant findings. One month later the patient presented with worsened symptoms and a repeat echocardiogram showed an increased mean aortic valve gradient of 87 mm Hg. The patient had to undergo reoperation for a surgical aortic valve replacement and was found to have an aortic bioprosthetic valve thrombus. This case suggests a mismatch between the aortic prosthesis and the patient's aortic root size.

Right Atrial Thrombosis Provoked by Central Venous Catheter: A Case Report.

Intracardiac thrombi are not uncommon, but right atrial (RA) thrombi are exceedingly rare. Thrombi can lead to a variety of complications, such as systemic and pulmonary embolism. While various imaging modalities are helpful in the diagnosis, an echocardiogram is the most commonly used one. Principle management of the condition involves anticoagulation. However, management can vary among different patient groups, depending on the location and size of thrombi. We present a case of an RA thrombosis due to dilation of the atria and trauma from an infected central venous catheter in a patient with a past medical history of pulmonary artery hypertension (PAH).

Therapeutic approaches to diastolic dysfunction.

Progressive abnormalities of passive stiffness or active relaxation of the myocardium that impair ventricular filling during diastole may be an important contributor to the development of heart failure in patients with preserved ejection fraction. In this review, we discuss the epidemiology and pathophysiology of diastolic dysfunction and heart failure with preserved ejection fraction, highlighting potential therapeutic approaches and exploring the limited available evidence base for improving clinical outcomes in patients with these challenging entities.

Improved prediction of outcome by contrast echocardiography determined left ventricular remodelling parameters compared to unenhanced echocardiography in patients following acute myocardial infarction.

AIMS: Contrast echocardiography has been shown to be a more accurate method of assessing left ventricular (LV) remodelling compared with unenhanced echocardiography after acute myocardial infarction (AMI). However, whether this translated into improved prediction of outcome is not known. METHODS AND RESULTS: Accordingly, a total of 89 consecutive patients undergoing contrast echocardiography and unenhanced echocardiography 7 to 10 days after AMI and reperfusion therapy were followed up for cardiac death (CD) and AMI. LV ejection fraction (LVEF), LV end-systolic volume (ESV), and LV end-diastolic volume were assessed by the two methods independently. Outcome data were obtained (mean 46 +/- 16 months).There were 15 (17%) events (eight CDs and seven AMIs). LVEF and ESV with contrast echocardiography were found to be independent multivariable predictors of CD (P = 0.04 and P = 0.02, respectively) and CD or AMI (P = 0.02 and P = 0.01, respectively). Furthermore, LVEF and ESV with contrast echocardiography provided incremental information for the prediction of CD (P = 0.004 and P = 0.004, respectively) and CD or AMI (P = 0.02 and P = 0.03, respectively). CONCLUSION: Contrast echocardiography provided improved prediction of outcome compared with unenhanced echocardiography following AMI.

Effect of angiotensin receptor blockade and antihypertensive drugs on diastolic function in patients with hypertension and diastolic dysfunction: a randomised trial.

BACKGROUND: Diastolic dysfunction might represent an important pathophysiological intermediate between hypertension and heart failure. Our aim was to determine whether inhibitors of the renin-angiotensin-aldosterone system, which can reduce ventricular hypertrophy and myocardial fibrosis, can improve diastolic function to a greater extent than can other antihypertensive agents. METHODS: Patients with hypertension and evidence of diastolic dysfunction were randomly assigned to receive either the angiotensin receptor blocker valsartan (titrated to 320 mg once daily) or matched placebo. Patients in both groups also received concomitant antihypertensive agents that did not inhibit the renin-angiotensin system to reach targets of under 135 mm Hg systolic blood pressure and under 80 mm Hg diastolic blood pressure. The primary endpoint was change in diastolic relaxation velocity between baseline and 38 weeks as determined by tissue doppler imaging. Analyses were done by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00170924. FINDINGS: 186 patients were randomly assigned to receive valsartan; 198 were randomly assigned to receive placebo. 43 patients were lost to follow-up or discontinued the assigned intervention. Over 38 weeks, there was a 12.8 (SD 17.2)/7.1 (9.9) mm Hg reduction in blood pressure in the valsartan group and a 9.7 (17.0)/5.5 (10.2) mm Hg reduction in the placebo group. The difference in blood pressure reduction between the two groups was not significant. Diastolic relaxation velocity increased by 0.60 (SD 1.4) cm/s from baseline in the valsartan group (p<0.0001) and 0.44 (1.4) cm/s from baseline in the placebo group (p<0.0001) by week 38. However, there was no significant difference in the change in diastolic relaxation velocity between the groups (p=0.29). INTERPRETATION: Lowering blood pressure improves diastolic function irrespective of the type of antihypertensive agent used.

Papillary fibroelastoma diagnosed through multimodality cardiac imaging: a rare tumour in an uncommon location with review of literature.

We describe the case of a woman presenting with transient ischaemic attack, who was found to have a papillary fibroelastoma arising from the aortic wall, an extremely rare location. We describe the multimodality imaging techniques used in diagnosing this patient and review the most recent literature on evaluation and management of patients with cardiac papillary fibroelastomas.

A 24-year-old male with a painful and cold lower extremity.

CLINICAL INTRODUCTION: A 24-year-old male presented to the emergency department with intense pain in his right lower extremity. He has a medical history significant for systemic lupus erythematosus and antiphospholipid syndrome. He also had four prior episodes of deep venous thromboses on rivaroxaban. The patient stated that early in the morning, he started to feel intense pain that started from his knee and progressed to his calf, with associated numbness and paraesthesia. On physical examination, the limb felt cold with absent right popliteal and dorsalis pedis pulses. He was immediately taken for embolectomy after discovery of a distal common femoral artery occlusion. The patient's blood cultures remained negative. X-plane imaging on real-time three-dimensional transoesophageal echocardiography (RT-3DTEE) of the aortic valve (figure 1A) and colour Doppler (figure 1B) are shown. QUESTION: What is the diagnosis and management for this patient (assuming the patient will stay anticoagulated for life)? Infective endocarditis (IE); antibiotics and valve replacementLibman-Sacks endocarditis; corticosteroidsIE; antibiotics onlyLibman-Sacks endocarditis; valve replacementLibman-Sacks endocarditis; continuing anticoagulation only heartjnl;103/10/765/HEARTJNL2016310872F1F1HEARTJNL2016310872F1Figure 1Visualisation of the aortic valve on (A) X-plane imaging on real-time three-dimensional transoesophageal echocardiography (RT-3DTEE) and (B) colour Doppler.

Real-Time Three-Dimensional Echocardiography: Characterization of Cardiac Anatomy and Function-Current Clinical Applications and Literature Review Update.

Our review of real-time three-dimensional echocardiography (RT3DE) discusses the diagnostic utility of RT3DE and provides a comparison with two-dimensional echocardiography (2DE) in clinical cardiology. A Pubmed literature search on RT3DE was performed using the following key words: transthoracic, two-dimensional, three-dimensional, real-time, and left ventricular (LV) function. Articles included perspective clinical studies and meta-analyses in the English language, and focused on the role of RT3DE in human subjects. Application of RT3DE includes analysis of the pericardium, right ventricular (RV) and LV cavities, wall motion, valvular disease, great vessels, congenital anomalies, and traumatic injury, such as myocardial contusion. RT3DE, through a transthoracic echocardiography (TTE), allows for increasingly accurate volume and valve motion assessment, estimated LV ejection fraction, and volume measurements. Chamber motion and LV mass approximation have been more accurately evaluated by RT3DE by improved inclusion of the third dimension and quantification of volumetric movement. Moreover, RT3DE was shown to have no statistical significance when comparing the ejection fractions of RT3DE to cardiac magnetic resonance (CMR). Analysis of RT3DE data sets of the LV endocardial exterior allows for the volume to be directly quantified for specific phases of the cardiac cycle, ranging from end systole to end diastole, eliminating error from wall motion abnormalities and asymmetrical left ventricles. RT3DE through TTE measures cardiac function with superior diagnostic accuracy in predicting LV mass, systolic function, along with LV and RV volume when compared with 2DE with comparable results to CMR.

Rationale and design: the VALsartan In Diastolic Dysfunction (VALIDD) Trial: evolving the management of diastolic dysfunction in hypertension.

BACKGROUND: Although 50% of hypertensive patients in the community are estimated to have diastolic dysfunction, there is no specific guideline for diastolic dysfunction therapy at present despite the condition's clear association with increased cardiovascular risk. Although the efficacy of angiotensin II receptor blockers (ARBs) in hypertension and left ventricular hypertrophy regression has been established, the effect of angiotensin II receptor blockade on intrinsic parameters of diastolic function has not been evaluated in large-scale studies. METHODS: The VALIDD Trial is an investigator-initiated randomized, controlled, double-blind clinical trial on approximately 350 patients designed to explore whether antihypertensive therapy with the ARB valsartan, in addition to standard therapy, would improve intrinsic diastolic properties of the myocardium in patients with hypertension and evidence of diastolic dysfunction. The result of such therapy will be compared with placebo after 38 weeks of treatment. The primary efficacy variable is change in early diastolic lateral mitral annular relaxation velocity measured by tissue Doppler imaging on week 38. CONCLUSIONS: We expect the VALIDD Trial to provide novel insights into the specific effects of ARBs on diastolic dysfunction, as assessed by tissue Doppler imaging, in hypertensive patients. The trial may provide clinically useful data on whether such therapy can directly improve diastolic function in patients with hypertension.