Immediate and Midterm Cardiac Remodeling After Surgical Pulmonary Valve Replacement in Adults With Repaired Tetralogy of Fallot: A Prospective Cardiovascular Magnetic Resonance and Clinical Study.

BACKGROUND: Pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot provides symptomatic benefit and right ventricular (RV) volume reduction. However, data on the rate of ventricular structural and functional adaptation are scarce. We aimed to assess immediate and midterm post-PVR changes and predictors of reverse remoeling. METHODS: Fifty-seven patients with repaired tetralogy of Fallot (age ≥16 y; mean age, 35.8±10.1 y; 38 male) undergoing PVR were prospectively recruited for cardiovascular magnetic resonance performed before PVR (pPVR), immediately after PVR (median, 6 d), and midterm after PVR (mPVR; median, 3 y). RESULTS: There were immediate and midterm reductions in indexed RV end-diastolic volumes and RV end-systolic volumes (RVESVi) (indexed RV end-diastolic volume pPVR versus immediately after PVR versus mPVR, 156.1±41.9 versus 104.9±28.4 versus 104.2±34.4 mL/m2; RVESVi pPVR versus immediately after PVR versus mPVR, 74.9±26.2 versus 57.4±22.7 versus 50.5±21.7 mL/m2; P<0.01). Normal postoperative diastolic and systolic RV volumes (the primary end point) achieved in 70% of patients were predicted by a preoperative indexed RV end-diastolic volume ≤158 mL/m2 and RVESVi ≤82 mL/m2. RVESVi showed a progressive decrease from baseline to immediate to midterm follow-up, indicating ongoing intrinsic RV functional improvement after PVR. Left ventricular ejection fraction improved (pPVR versus mPVR, 59.4±7.6% versus 61.9±6.8%; P<0.01), and right atrial reverse remodeling occurred (pPVR versus mPVR, 15.2±3.4 versus 13.8±3.6 cm2/m2; P<0.01). Larger preoperative RV outflow tract scar was associated with a smaller improvement in post-PVR RV/left ventricular ejection fraction. RV ejection fraction and peak oxygen uptake predicted mortality (P=0.03) over a median of 9.5 years of follow-up. CONCLUSIONS: Significant right heart structural reverse remodeling takes place immediately after PVR, followed by a continuing process of further biological remodeling manifested by further reduction in RVESVi. PVR before RVESVi reaches 82 mL/m2 confers optimal chances of normalization of RV function.

Severely impaired left ventricular function: tissue characterization by cardiovascular magnetic resonance in a clinical dilemma.

In patients with symptoms of heart failure, identifying the underlying cause of cardiomyopathy is helpful to establish the diagnosis and to guide therapy. The differential diagnosis of cardiomyopathy can be challenging based on clinical findings. We report the case of a patient who represented a clinical dilemma (cardiac sarcoidosis or ischaemic heart disease), in whom cardiovascular magnetic resonance was a clinically valuable tool to distinguish dual cardiac pathology due to its unique, non-invasive, tissue characterization capabilities.

Dobutamine stress-induced ischemic right ventricular dysfunction and its relation to cardiac output in patients with three-vessel coronary artery disease with angina-like symptoms.

We investigated markers of ischemic dysfunction and their relation to overall right ventricular (RV) performance during dobutamine stress echocardiography in patients who had coronary artery disease. Thirty-three patients (58 +/- 10 years old) who had 3-vessel coronary artery disease were compared with 17 age-matched controls (58 +/- 11 years old). RV long-axis amplitude (M mode), systolic and diastolic myocardial tissue Doppler velocities, and filling and ejection velocities were measured, and cardiac output (CO) was calculated at rest and during peak stress. There was no difference in RV size (inlet dimension <3.5 cm), RV systolic long-axis amplitude, systolic and diastolic velocities, peak early/late diastolic velocity ratio, and RV CO between patients and controls at rest. During stress, RV systolic long-axis amplitude increased in controls (from 24 +/- 6 to 30 +/- 5 mm) and CO increased significantly (from 4.9 +/- 1.2 to 12.5 +/- 2.1 L/min, p <0.001 for the 2 items). In contrast, RV amplitude did not change with stress in patients (from 24 +/- 5 to 22 +/- 6 mm, p = NS), and the stress-increment in CO was augmented (from 4.2 +/- 1.2 to 8.3 +/- 2.0 L/min, p <0.001 vs control stress increment). Failure to increase RV systolic amplitude >2 mm was 79% sensitive and 88% specific for detecting ischemic RV dysfunction, and there was a close correlation between stress-induced change in RV systolic amplitude and change in CO in patients (r = 0.56, p <0.001). Early diastolic velocity increased in controls (from 10.8 +/- 3.2 to 13.1 +/- 3.6 cm/s, p <0.01) but did not change in patients (from 11.5 +/- 3.7 to 11.3 +/- 4.8 cm/s, p = NS). RV shortening after ejection did not appear in any control subject but did develop in 8 of 33 patients, thus contributing to the decrease in RV peak early/late diastolic velocity ratio in patients (from 1.1 +/- 0.3 to 0.76 +/- 0.4, p <0.001) compared with that in controls (1.3 +/- 0.3 to 1.0 +/- 0.2, p <0.001). In conclusion, markers of RV dysfunction are not related to left ventricular wall motion score index or long-axis changes with stress.

Pulmonary vasospasm in systemic sclerosis: noninvasive techniques for detection.

In a subgroup of patients with systemic sclerosis (SSc), vasospasm affecting the pulmonary circulation may contribute to worsening respiratory symptoms, including dyspnea. Noninvasive assessment of pulmonary blood flow (PBF), utilizing inert-gas rebreathing (IGR) and dual-energy computed-tomography pulmonary angiography (DE-CTPA), may be useful for identifying pulmonary vasospasm. Thirty-one participants (22 SSc patients and 9 healthy volunteers) underwent PBF assessment with IGR and DE-CTPA at baseline and after provocation with a cold-air inhalation challenge (CACh). Before the study investigations, participants were assigned to subgroups: group A included SSc patients who reported increased breathlessness after exposure to cold air (n = 11), group B included SSc patients without cold-air sensitivity (n = 11), and group C patients included the healthy volunteers. Median change in PBF from baseline was compared between groups A, B, and C after CACh. Compared with groups B and C, in group A there was a significant decline in median PBF from baseline at 10 minutes (-10%; range: -52.2% to 4.0%; P < 0.01), 20 minutes (-17.4%; -27.9% to 0.0%; P < 0.01), and 30 minutes (-8.5%; -34.4% to 2.0%; P < 0.01) after CACh. There was no significant difference in median PBF change between groups B or C at any time point and no change in pulmonary perfusion on DE-CTPA. Reduction in pulmonary blood flow following CACh suggests that pulmonary vasospasm may be present in a subgroup of patients with SSc and may contribute to worsening dyspnea on exposure to cold.

64-multislice computed tomography in consecutive patients with suspected or proven coronary artery disease: initial single center experience.

BACKGROUND: The improved accuracy of 64-multislice CT (MSCT) suggests that this technique may replace other non-invasive methods to detect clinically significant coronary atherosclerosis. The aim of the present study was to assess the clinical usefulness of in consecutive patients with suspected or proven coronary artery disease (CAD). METHODS: 64-MSCT was performed in 56 patients (age 56+/-16 years, 50 male) with suspected or proven CAD (35 patients with chest pain/positive provocative tests/risk factors), 18 with documented significant CAD, CABG surgery or stent implantation, 3 non-assessable with selective angiography because of peripheral vascular disease or large aneurysms of the ascending aorta. RESULTS: One patient was excluded because of contrast extravasation. In 30/55 patients (54%) 64-MSCT excluded significant coronary stenoses; in 13/55 patients (24%) angiography and/or angioplasty were recommended to treat (3) 50% diameter stenoses shown by MSCT, a diagnosis confirmed in 9 (81.8%) of the 11 patients who underwent further investigations; 12/55 patients (22%) needed angiography or other preliminary non-invasive tests because 64-MSCT was of insufficient diagnostic quality. Predictors of a poor diagnostic quality of 64-MSCT were older age (64+/-8 vs. 55+/-11 years, p<0.007), diabetes mellitus (42% vs. 9%, p=0.017), previous angiography, angioplasty or CABG surgery (83% vs. 26%, p<0.0001), Agatston score>400 (75% vs. 21%, p<0.002). CONCLUSION: 64-MSCT provided complete diagnostic coronary images sufficient for clinical decision making in the vast majority (78%) of a consecutive group of patients studied for suspected or proven CAD. Predictors of diagnostic failure were massive calcification, long-standing known coronary atherosclerosis or previous CABG/stent implantation, old age and diabetes mellitus.

Valve replacement without preoperative cardiac catheterization: a 8 year follow-up study

Em 1978, substituiçäo de valvas cardíacas foi realizada em 305 pacientes em Brompton Hospital, Londres. Em 243 (grupo 1) o cateterismo cardíaco näo foi realizado no tempo em que os pacientes foram referidos. Deste grupo, 184 doentes foram enviados para a cirurgia sem cateterismo (grupo 1-A) e 59 (grupo 1-B) foram submetidos a avaliaçäo hemodinâmica por dúvida acerca da severidade da lesäo valvar e da evidência clínica de doença da aorta ou doença coronariana. Um grupo adicional de 62 pacientes (grupo 2) que já havia sido cateterizado, serviu como índice comparativo da conduta convencional. Num seguimento de 8 anos, dados sobre 247 pacientes foram obtidos. A maioria dos doentes de todos os grupos está assintomática. Näo se observaram diferenças com relaçäo a mortalidade, complicaçöes e situaçäo clínica nos diferentes grupos. Conclui-se que é possível dispensar cateterismo cardíaco na maioria dos doentes que necessitam substituto valvar