Diagnostic Accuracy of Spiral Whole-Heart Quantitative Adenosine Stress Cardiovascular Magnetic Resonance With Motion Compensated L1-SPIRIT.

BACKGROUND: Variable density spiral (VDS) pulse sequences with motion compensated compressed sensing (MCCS) reconstruction allow for whole-heart quantitative assessment of myocardial perfusion but are not clinically validated. PURPOSE: Assess performance of whole-heart VDS quantitative stress perfusion with MCCS to detect obstructive coronary artery disease (CAD). STUDY TYPE: Prospective cross sectional. POPULATION: Twenty-five patients with chest pain and known or suspected CAD and nine normal subjects. FIELD STRENGTH/SEQUENCE: Segmented steady-state free precession (SSFP) sequence, segmented phase sensitive inversion recovery sequence for late gadolinium enhancement (LGE) imaging and VDS sequence at 1.5 T for rest and stress quantitative perfusion at eight short-axis locations. ASSESSMENT: Stenosis was defined as ≥50% by quantitative coronary angiography (QCA). Visual and quantitative analysis of MRI data was compared to QCA. Quantitative analysis assessed average myocardial perfusion reserve (MPR), average stress myocardial blood flow (MBF), and lowest stress MBF of two contiguous myocardial segments. Ischemic burden was measured visually and quantitatively. STATISTICAL TESTS: Student's t-test, McNemar's test, chi-square statistic, linear mixed-effects model, and area under receiver-operating characteristic curve (ROC). RESULTS: Per-patient visual analysis demonstrated a sensitivity of 84% (95% confidence interval [CI], 60%-97%) and specificity of 83% [95% CI, 36%-100%]. There was no significant difference between per-vessel visual and quantitative analysis for sensitivity (69% [95% CI, 51%-84%] vs. 77% [95% CI, 60%-90%], P = 0.39) and specificity (88% [95% CI, 73%-96%] vs. 80% [95% CI, 64%-91%], P = 0.75). Per-vessel quantitative analysis ROC showed no significant difference (P = 0.06) between average MPR (0.68 [95% CI, 0.56-0.81]), average stress MBF (0.74 [95% CI, 0.63-0.86]), and lowest stress MBF (0.79 [95% CI, 0.69-0.90]). Visual and quantitative ischemic burden measurements were comparable (P = 0.85). DATA CONCLUSION: Whole-heart VDS stress perfusion demonstrated good diagnostic accuracy and ischemic burden evaluation. No significant difference was seen between visual and quantitative diagnostic performance and ischemic burden measurements. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 2.

Diagnosis and Treatment of Intracardiac Thrombus.

ABSTRACT: Intracardiac thrombi can occur in a variety of locations and are frequently encountered in clinical practice. Yet evidence-based guidance for clinicians managing patients with intracardiac thrombi is often limited. This review summarizes what is known regarding the prevalence of intracardiac thrombus, diagnostic strategies, clinical relevance, and treatment options, focusing on four specific types of thrombus for which recent research has shifted clinical understanding and treatment decisions: (1) left atrial appendage thrombus, (2) cardiac implantable electronic device lead thrombus, (3) bioprosthetic aortic valve thrombus, and (4) left ventricular thrombus. Additional studies, ideally prospective, randomized, and head-to-head in design, are needed to better inform best practices in patients with intracardiac thrombi.

Risk of skin cancer in multiple myeloma patients: a retrospective cohort study.

Immunosuppressed patients are known to have an increased incidence of skin cancer. Patients with multiple myeloma (MM) show impaired immune function. In the past, because of poor survival, the incidence of specific secondary primary malignancies such as skin cancer among these patients was difficult to establish. With more effective MM therapies that have emerged in recent years, these patients are living markedly longer, and therefore, it becomes of increasing importance to determine whether their risk of developing other medical problems such as skin cancer is increased. We performed a retrospective cohort study of 205 myeloma patients and 193 age-, race-, and gender-matched control subjects to assess the incidence of skin cancers among patients with MM and determine the specific types of and risk factors for skin cancer. We found that there is an increased occurrence of skin cancer among patients with MM compared to control subjects (26.8% vs. 16.1% in controls; P = 0.009). Among specific types of skin cancer, the proportion of patients with squamous cell carcinoma (SCC) was higher than controls (P = 0.016). In addition to MM diagnosis, older age and Caucasian ethnicity were predictors of skin cancer of any type. Furthermore, older age was also a predictor of SCC.

Anticoagulation for the acute management of ischemic stroke.

Few prospective studies support the use of anticoagulation during the acute phase of ischemic stroke, though observational data suggest a role in certain populations. Depending on the mechanism of stroke, systemic anticoagulation may prevent recurrent cerebral infarction, but concomitantly carries a risk of hemorrhagic transformation. In this article, we describe a case where anticoagulation shows promise for ischemic stroke and review the evidence that has discredited its use in some circumstances while showing its potential in others.

A Review of Current and Evolving Imaging Techniques in Cardiac Amyloidosis.

Purpose of review: Establishing an early, efficient diagnosis for cardiac amyloid (CA) is critical to avoiding adverse outcomes. We review current imaging tools that can aid early diagnosis, offer prognostic information, and possibly track treatment response in CA. Recent findings: There are several current conventional imaging modalities that aid in the diagnosis of CA including electrocardiography, echocardiography, bone scintigraphy, cardiac computed tomography (CT), and cardiac magnetic resonance (CMR) imaging. Advanced imaging techniques including left atrial and right ventricular strain, and CMR T1 and T2 mapping as well as ECV quantification may provide alternative non-invasive means for diagnosis, more granular prognostication, and the ability to track treatment response. Summary: Leveraging a multimodal imaging toolbox is integral to the early diagnosis of CA; however, it is important to understand the unique role and limitations posed by each modality. Ongoing studies are needed to help identify imaging markers that will lead to an enhanced ability to diagnose, subtype and manage this condition.

Transcatheter aortic valve replacement: a palliative approach to infective endocarditis.

An 88-year-old man with small lymphocytic lymphoma presented to the hospital with shortness of breath and was diagnosed with heart failure. Serial blood cultures and echocardiography revealed Staphylococcus epidermidis endocarditis, complicated by severe aortic regurgitation. Despite intravenous antibiotic therapy and aggressive intravenous diuresis therapy in the hospital, he decompensated into cardiogenic shock, requiring invasive haemodynamic monitoring and inotrope therapy. With multidisciplinary discussion involving the patient and his children, there was a joint decision that at his advanced age, he would not pursue surgical aortic valve replacement and instead proceed with a transcatheter aortic valve replacement (TAVR) with palliative intent. He underwent TAVR with subsequent symptomatic and functional improvement as well as resolution of cardiogenic shock.

Functional and Economic Impact of INOCA and Influence of Coronary Microvascular Dysfunction.

OBJECTIVES: This study sought to better characterize the quality of life and economic impact in patients with symptoms of ischemia and no obstructive coronary disease (INOCA) and to identify the influence of coronary microvascular dysfunction (CMD). BACKGROUND: Patients with INOCA have a high symptom burden and an increased incidence of major adverse cardiac events. CMD is a frequent cause of INOCA. The morbidity associated with INOCA and CMD has not been well-characterized. METHODS: Sixty-six patients with INOCA underwent stress cardiac magnetic resonance with calculation of myocardial perfusion reserve (MPR); MPR 2.0 to 2.4 was considered borderline-reduced (possible CMD) and MPR <2.0 was defined as reduced (definite CMD). Subjects completed quality of life questionnaires to assess the morbidity and economic impact of INOCA. Questionnaire results were compared between INOCA patients with and without CMD. In addition, logistic regression was used to determine the predictors of CMD within the INOCA population. RESULTS: The prevalence of definite CMD was 24%. Definite or borderline CMD was present in 59% (MPR ≤2.4). Patients with INOCA reported greater physical limitation, angina frequency, and reduced quality of life compared to referent stable coronary artery disease and acute myocardial infarction populations. In addition, Patients with INOCA reported frequent time missed from work and work limitations, suggesting a substantial economic impact. No difference was observed in reported symptoms between INOCA patients with and without CMD. Glomerular filtration rate and body-mass index were significant predictors of CMD in multivariable regression analysis. CONCLUSIONS: INOCA is associated with high morbidity similar to other high-risk cardiac populations, and work limitations reported by Patients with INOCA suggest a substantial economic impact. CMD is a common cause of INOCA but is not associated with increased morbidity. These results suggest that there is significant symptom burden in the INOCA population regardless of etiology.

Cardiac Magnetic Resonance Assessment of Response to Cardiac Resynchronization Therapy and Programming Strategies.

OBJECTIVES: The objective was to determine the feasibility and effectiveness of cardiac magnetic resonance (CMR) cine and strain imaging before and after cardiac resynchronization therapy (CRT) for assessment of response and the optimal resynchronization pacing strategy. BACKGROUND: CMR with cardiac implantable electronic devices can safely provide high-quality right ventricular/left ventricular (LV) ejection fraction (RVEF/LVEF) assessments and strain. METHODS: CMR with cine imaging, displacement encoding with stimulated echoes for the circumferential uniformity ratio estimate with singular value decomposition (CURE-SVD) dyssynchrony parameter, and scar assessment was performed before and after CRT. Whereas the pre-CRT scan constituted a single "imaging set" with complete volumetric, strain, and scar imaging, multiple imaging sets with complete strain and volumetric data were obtained during the post-CRT scan for biventricular pacing (BIVP), LV pacing (LVP), and asynchronous atrial pacing modes by reprogramming the device outside the scanner between imaging sets. RESULTS: 100 CMRs with a total of 162 imaging sets were performed in 50 patients (median age 70 years [IQR: 50-86 years]; 48% female). Reduction in LV end-diastolic volumes (P = 0.002) independent of CRT pacing were more prominent than corresponding reductions in right ventricular end-diastolic volumes (P = 0.16). A clear dependence of the optimal CRT pacing mode (BIVP vs LVP) on the PR interval (P = 0.0006) was demonstrated. The LVEF and RVEF improved more with BIVP than LVP with PR intervals ≥240 milliseconds (P = 0.025 and P = 0.002, respectively); the optimal mode (BIVP vs LVP) was variable with PR intervals <240 milliseconds. A lower pre-CRT displacement encoding with stimulated echoes (DENSE) CURE-SVD was associated with greater improvements in the post-CRT CURE-SVD (r = -0.69; P < 0.001), LV end-systolic volume (r = -0.58; P < 0.001), and LVEF (r = -0.52; P < 0.001). CONCLUSIONS: CMR evaluation with assessment of multiple pacing modes during a single scan after CRT is feasible and provides useful information for patient care with respect to response and the optimal pacing strategy.

Off-label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi.

Importance: Left ventricular (LV) thrombi can arise in patients with ischemic and nonischemic cardiomyopathies. Anticoagulation is thought to reduce the risk of stroke or systemic embolism (SSE), but there are no high-quality data on the effectiveness of direct oral anticoagulants (DOACs) for this indication. Objective: To compare the outcomes associated with DOAC use and warfarin use for the treatment of LV thrombi. Design, Setting, and Participants: A cohort study was performed at 3 tertiary care academic medical centers among 514 eligible patients with echocardiographically diagnosed LV thrombi between October 1, 2013, and March 31, 2019. Follow-up was performed through the end of the study period. Exposures: Type and duration of anticoagulant use. Main Outcomes and Measures: Clinically apparent SSE. Results: A total of 514 patients (379 men; mean [SD] age, 58.4 [14.8] years) with LV thrombi were identified, including 300 who received warfarin and 185 who received a DOAC (64 patients switched treatment between these groups). The median follow-up across the patient cohort was 351 days (interquartile range, 51-866 days). On unadjusted analysis, DOAC treatment vs warfarin use (hazard ratio [HR], 2.71; 95% CI, 1.31-5.57; P = .01) and prior SSE (HR, 2.13; 95% CI, 1.22-3.72; P = .01) were associated with SSE. On multivariable analysis, anticoagulation with DOAC vs warfarin (HR, 2.64; 95% CI, 1.28-5.43; P = .01) and prior SSE (HR, 2.07; 95% CI, 1.17-3.66; P = .01) remained significantly associated with SSE. Conclusions and Relevance: In this multicenter cohort study of anticoagulation strategies for LV thrombi, DOAC treatment was associated with a higher risk of SSE compared with warfarin use, even after adjustment for other factors. These results challenge the assumption of DOAC equivalence with warfarin for LV thrombi and highlight the need for prospective randomized clinical trials to determine the most effective treatment strategies for LV thrombi.

Myocardial T1 and ECV Measurement: Underlying Concepts and Technical Considerations.

Myocardial native T1 and extracellular volume fraction (ECV) mapping have emerged as cardiac magnetic resonance biomarkers providing unique insight into cardiac pathophysiology. Single breath-hold acquisition techniques, available on clinical scanners across multiple vendor platforms, have made clinical T1 and ECV mapping a reality. Although the relationship between changes in native T1 and alterations in cardiac microstructure is complex, an understanding of how edema, blood volume, myocyte and interstitial expansion, lipids, and paramagnetic substances affect T1 and ECV can provide insight into how and why these parameters change in various cardiac pathologies. The goals of this state-of-the-art review will be to review factors influencing native T1 and ECV, to describe how native T1 and ECV are measured, to discuss potential challenges and pitfalls in clinical practice, and to describe new T1 mapping techniques on the horizon.

Emerging Techniques for Cardiovascular PET.

The application of positron emission tomography (PET) to cardiac disease has yielded tremendous developments in the evaluation of coronary artery, myocardial, and valvular heart disease over the past several decades. These advances have included development of new radiotracers, incremental technological improvements, and coupling of PET with other non-invasive cardiac imaging modalities. The current era has seen rapid, successive and wide-ranging advances in PET myocardial perfusion and metabolic imaging. This review will address emerging techniques in cardiovascular PET imaging, including the measurement of absolute myocardial blood flow (MBF), use of novel tracers, and other advances in heart failure, infection imaging, and valvular disease.

Left ventricular thrombi after STEMI in the primary PCI era: A systematic review and meta-analysis.

BACKGROUND: Left ventricular (LV) thrombus formation following myocardial infarction (MI) has not been well characterized since the advent of primary percutaneous coronary intervention (pPCI). Ascertainment of the utility of prophylactic anticoagulation is hindered by the lack of reliable information on its modern incidence. We sought to provide an estimate of the rate of LV thrombus formation in patients treated with pPCI for ST segment elevation MI (STEMI) by means of a systematic review and meta-analysis. METHODS: We searched Ovid MEDLINE and Ovid EMBASE databases for studies between 1990 and 2015 documenting LV thrombi after STEMI treated with pPCI. We estimated the rate of echocardiographically-diagnosed LV thrombi within 90days of pPCI, calculating the rate of LV thrombi after STEMI in any infarct territory as well as only anterior infarcts. RESULTS: From an initial yield of 1144 studies, inclusion criteria were met by 19 studies, including 10,076 patients across 27 centers in 9 countries. Rate of LV thrombi after all STEMI was 2.7% (95% CI 1.9%-3.5%) and 9.1% (95% CI 6.6%-11.6%) after anterior STEMI. Among anterior STEMI, there was an inverse relationship between size of study and rate of LV thrombi. CONCLUSIONS: LV thrombi persist as an important part of the management of STEMI after pPCI, particularly among anterior infarcts. Estimating risk of thrombus formation and embolization as well as utility of treatment remains critical.