Diagnosis and staging of cardiac masses: additional value of CMR with 18F-FDG-PET compared to CMR with CECT.

PURPOSE: Characterization of malignant cardiac masses is usually performed with cardiac magnetic resonance (CMR) and staging with whole-body contrast-enhanced computed tomography (CECT). In this study, our objective was to evaluate the role of 18Fluor-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) with CMR for both characterization and staging of cardiac masses. METHODS: Patients with cardiac masses who underwent CMR, CECT, and 18F-FDG-PET were retrospectively identified. For the characterization of cardiac masses, we calculated the respective performances of CMR alone, 18F-FDG-PET alone, and the combination of 18F-FDG-PET and CMR. For staging, we compared head-to-head the respective performances of 18F-FDG-PET and CECT. Histology served as gold standard for malignancy, and response to anticoagulation for thrombus. RESULTS: In a total of 28 patients (median age 60.5 years, 60.7% women), CMR accurately distinguished malignant from benign masses with sensitivity (Se) of 86.7%, specificity (Sp) of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 86.7%, and accuracy of 92.9%. 18F-FDG-PET demonstrated 93.3% Se, 84.6% Sp, 87.5% PPV, 91.7% NPV, and 89.3% accuracy. Combining CMR with 18F-FDG-PET allowed to benefit from the high sensitivity of 18F-FDG-PET (92.9%) and the excellent specificity of CMR (100%) for malignant diseases. For staging, 18F-FDG-PET outperformed CECT on per-patient (66.7% vs 55.6% correct diagnosis, respectively), per-organ (10 vs 7 organs, respectively), and per-lesion basis (> 29 vs > 25 lesions, respectively). CONCLUSION: Combining 18F-FDG-PET with CMR improved the characterization of cardiac masses compared to each modality alone. Additionally, the diagnostic performance of 18F-FDG-PET was better than CECT for staging. This study suggests that the combination of CMR and 18F-FDG-PET is the most effective for the characterization of cardiac masses and the staging of these lesions.

Nonsteroidal anti-inflammatory drug treatment for postoperative pericardial effusion: a multicenter randomized, double-blind trial.

BACKGROUND: The incidence of asymptomatic pericardial effusion is high after cardiac surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in this setting, but no study has assessed their efficacy. OBJECTIVE: To assess whether the NSAID diclofenac is effective in reducing postoperative pericardial effusion volume. DESIGN: Multicenter randomized, double-blind, placebo-controlled study. (Clinical trials.gov registration number: NCT00247052) SETTING: 5 postoperative cardiac rehabilitation centers. PATIENTS: 196 patients at high risk for tamponade because of moderate to large persistent pericardial effusion (grade 2, 3, or 4 on a scale of 0 to 4, as measured by echocardiography) more than 7 days after cardiac surgery. INTERVENTION: Random assignment at each site in blocks of 4 to diclofenac, 50 mg, or placebo twice daily for 14 days. MEASUREMENTS: The main end point was change in effusion grade after 14 days of treatment. Secondary end points included frequency of late cardiac tamponade. RESULTS: The initial mean pericardial effusion grade was 2.58 (SD, 0.73) for the placebo group and 2.75 (SD, 0.81) for the diclofenac group. The 2 groups showed similar mean decreases from baseline after treatment (-1.08 grades [SD, 1.20] for the placebo group vs. -1.36 (SD, 1.25) for the diclofenac group). The mean difference between groups was -0.28 grade (95% CI, -0.63 to 0.06 grade; P = 0.105). Eleven cases of late cardiac tamponade occurred in the placebo group and 9 in the diclofenac group (P = 0.64). These differences persisted after adjustment for grade of pericardial effusion at baseline, treatment site, and type of surgery. LIMITATION: The sample was not large enough to find small beneficial effects of diclofenac or assess the cardiovascular tolerance of diclofenac. CONCLUSION: In patients with pericardial effusion after cardiac surgery, diclofenac neither reduced the size of the effusions nor prevented late cardiac tamponade. PRIMARY FUNDING SOURCE: French Society of Cardiology.

Treatment of left ventricular thrombi with a low molecular weight heparin.

BACKGROUND: Once a diagnosis of left ventricular thrombus has been established, the classical attitude consists in the administration of unfractionated heparin relayed by oral anticoagulation therapy. However, the use of unfractionated heparins in this indication was only assessed in an open, non-randomized study with no control group, including 23 patients. On the other hand, although low molecular weight heparins are routinely used in some departments, there are no studies available concerning these agents in this indication. The aim of this study was to evaluate the feasibility of low molecular weight heparin therapy in patients with left ventricular thrombi. METHODS: The study was a prospective, non-randomized, open-label trial. All patients with a new left ventricular thrombus diagnosed between September 2000 and September 2003 received enoxaparine 100 IU/kg twice daily for a mean duration of 13 days. A relay treatment with fluindione was initiated on day 5. The left ventricular thrombus outcome was followed for 3 weeks by bi-weekly transthoracic echocardiography. RESULTS: 26 left ventricular thrombi were diagnosed over the 3-year study period: 19 in post-infarct patients with a history of anterior myocardial infarction and 7 in patients with dilated cardiomyopathy. The mean thrombus area decreased from 2.30+/-0.32 to 0.36+/-0.11 cm2 (p<0.0001). Nineteen thrombi out of twenty-six (73%) disappeared during the treatment period. No thrombocytopenia or hemorrhagic events were observed. One transient ischemic attack was reported. CONCLUSION: This preliminary study suggests that low molecular weight heparins are well tolerated and efficient in terms of left ventricular thrombi disappearance or size reduction.

Benefits of exercise training in chronic heart failure.

Exercise training performed in cardiac rehabilitation centres is an adjuvant therapy in chronic heart failure patients with left ventricular dysfunction; it decreases the deleterious consequences of chronic heart failure. Exercise training attenuates neurohormonal stimulation, the production of proinflammatory cytokines and natriuretic peptide overexpression. Trained patients showed a significant decrease in the peripheral organ injuries encountered in chronic heart failure, with a reduction in vascular resistance and improvements in endothelial dysfunction and the oxidative capacity of peripheral muscles, without a deleterious effect on left ventricular remodelling. Ultimately, exercise training leads to a notable improvement in ventilatory capacity. These beneficial effects are accompanied by improvements in symptoms at rest, exercise capacity and quality of life. Several training programmes are in current use: exercise training sessions always include endurance exercise performed either at a constant load intensity or with interval training, combining periods of exercise performed at high intensity with periods performed at low intensity. Most of the time, training programmes also include resistance training sessions, which improves large muscle strength. Exercise training programmes seem to have a favourable effect on prognosis, even if the results of Heart Failure: a Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) remain controversial, emphasizing the difficulty in monitoring observance and the importance of compliance with a long-term exercise training programme. Patients who do not improve their exercise capacity significantly after an exercise training programme have a poorer prognosis.

Determination of exercise training level in coronary artery disease patients on beta blockers.

OBJECTIVES: To compare the intensity of three exercise training regimens. BACKGROUND: During a cardiac rehabilitation program coronary artery disease (CAD) patients should be trained at an intensity as close as possible to the ventilatory threshold (VT) level. The precise way to obtain this intensity of training during the sessions, however, remains unclear. METHODS: In stable beta-blocked CAD patients, heart rate (HR) and workload (WL) at the VT were determined from a cardiopulmonary exercise test. The 3 following days, each patient performed (in a randomized order) one bicycle training session per day at an intensity determined by (i) HR at VT, (ii) WL at VT, (iii) patient's feelings (14 on the Borg scale). HR, WL, systolic blood pressure, oxygen consumption (VO2) and the respiratory exchange ratio were monitored during each session, to compare the intensity of each regimen. RESULTS: Twenty patients, 57+/-10 years old were included. VO2, WL, HR and systolic blood pressure were significantly higher in the sessions driven by feelings and WL, than in the HR-driven sessions. As respiratory exchange ratio remained less than 1, we can assume that there was no important and deleterious participation of anaerobic metabolism. CONCLUSION: Classical training HR prescription could lead to undertrain CAD patients, although a training session prescription driven by the feelings or by the WL observed at VT allows the patients to train at a higher--but still aerobic--intensity.