Echocardiographic characteristics of non-resectional ring-only valve repair in mitral valve prolapse.

BACKGROUND: Simple mitral valve repair (MVR) using a ring-only approach (ROA) was recently proposed for some complex forms of bileaflet myxomatous mitral valve prolapse (MVP). Nevertheless, few data are available concerning the characteristics of MVP patients that may benefit from this simple repair technique. METHODS: Based on 39 consecutive patients (28 men; mean age 57 ± 15) with severe primary Mitral regurgitation (MR) caused by bileaflet MVP referred for MVR, we sought to identify the preoperative echocardiographic parameters associated with successful ROA repair. RESULTS: Twenty-three patients (59%) underwent standard resectional MVR (SMVR) while 16 (41%) underwent ROA. Cardiopulmonary bypass and cross clamp times were lower in ROA than in SMVR (74 ± 27 min vs 99 ± 42 min and 49 ± 19 min vs 70 ± 25 min, respectively, p = 0.03 and p = 0.005). ROA patients were more frequently women (50% vs 13%, p = 0.027). Echocardiographic characteristics of successful ROA were mid-late systolic MR, a paradoxical systolic papillary muscle displacement, and paradoxical systolic annulus expansion (PAE). A prolapsing depth <10 mm, the absence of flail leaflet and ruptured chordae, the presence of multiple jets, more often in the central part of the valve were also associated with ROA. Non hemodynamic systolic anterior motion and residual trivial MR tended to be more frequent in ROA than in SMVR. CONCLUSION: Simple and fast MVR using a ROA is feasible in 4/10 patients with complex forms of bileaflet MVP. Successful ROA patients were more frequently women, with mid-late systolic central multiple jet, low prolapse depth, absence of chordal rupture or flail leaflet and PAE.

Extensive intra-myocardial calcifications: Value of multimodality imaging.

BACKGROUND: Massive myocardial calcification is a very rare finding. INTRODUCTION: Accurate identification and characteriation may help the clinicians to determine the etiology and clinical significance. RESULTS: In this case, the diagnostic pathway excluded previous myocardial infarction, myocarditis, and calcium-phosphate disorders. A possible dystrophic etiology was considered. DISCUSSION: There are no standardized imaging features available to classify specific subtypes of intra-myocardial calcifications. The relative merits of computed tomography and cardiac magnetic resonance (CMR) in providing complimentary diagnostic information in the evaluation of calcific myocardial lesions are shown. CONCLUSION: Knowledge of the potential etiology and their imging patterns are important to provide a concise and accurate differential diagnosis.

Percutaneous closure of a paravalvular prosthetic mitral leak complicated by need for acute hemodialysis.

A case of a severe paravalvular mechanical mitral prosthesis leak (PVL) in a high-risk surgical patient, complicated with acute heart failure at presentation is described. Considering the high surgical risk and the specific echocardiographic features that would prevent the interventional cardiologist to have a direct access to the PVL with a traditional vascular plug or duct occluder, a percutaneous PVL closure with an Amplatzer-Amulet (Abbott, Abbott Park, Illinois, United States) LAA device (28 mm) was chosen for the contiguity of the PVL to the left atrial appendage (LAA). A new-onset hemolysis post-PVL closure and severe renal failure requiring hemodialysis occurred after the procedure, treated with surgical device removal and leak suture. To the best of our knowledge, this is the first case that describes the attempt to close a PVL, contiguous to the LAA, using the Amulet device. The attempt to close a PVL with these features with an Amplatzer-Amulet device, although promising, does not appear completely safe to reach the goal, as in our case. In our opinion, the most important reasons are that specific technical recommendations and broad experiences are lacking. Indeed, specific outcomes of this kind of approach are, to date, still unknown.

Performance of a new fully automated transthoracic three-dimensional echocardiographic software for quantification of left cardiac chamber size and function: Comparison with 3 Tesla cardiac magnetic resonance.

PURPOSE: To evaluate the accuracy and reproducibility of a new fully automated fast three-dimensional (3D) transthoracic echocardiography (TTE) software for the simultaneous assessment of left atrial (LA) volumes and LA ejection fraction (EF), left ventricular (LV) volumes, LV mass, and LVEF, and to compare the results obtained with a cardiac magnetic resonance (CMR) reference. METHODS: We included retrospectively 56 patients (46 men; mean age 63 ± 13 years) in sinus rhythm who had had comprehensive 3D TTE and CMR examinations within 24 hours. RESULTS: Despite a slight underestimation of LV and LA volumes, LVEF and LAEF were similar using CMR or 3DTTE (58% ± 16% vs 58% ± 12%; P = .65 and 45% ± 14% vs 46% ± 15%; P = .38, respectively) in the total population. Despite significant correlation between TTE and CMR measurements (r = 0.78; P < .001), 3D TTE underestimated LV mass (bias = -27 ± 35 g). CONCLUSION: 3D TTE using a new-generation fully automated software is a fast and reproducible imaging modality for simultaneous extensive quantification of left heart chambers size and function in routine practice. Potential underestimation of LA volume and LV mass, and of LVEF in patients with LVEF <50%, should be taken into consideration.

Incremental value of normal adenosine perfusion cardiac magnetic resonance: Long-term outcome.

BACKGROUND: The purpose of the study was to determine the long-term prognostic value of normal adenosine stress cardiac magnetic resonance imaging (CMR) in patients referred for evaluation of myocardial ischemia. METHODS: We reviewed 300 consecutive patients (age 65 ± 11 years, 74% male) with suspected or known coronary disease and normal wall motion who had undergone adenosine stress CMR negative for ischemia and scar. Most patients were at intermediate risk of coronary artery disease. The end points studied were all causes of mortality and major adverse cardiac events, including cardiac death, myocardial infarction, revascularization, and hospitalization for unstable angina. RESULTS: During a mean follow-up of 5.5 years (mean = 5.4 ± 1.1), 16 patients died because of various causes (cardiac death in 5 patients). Three patients had a nonfatal myocardial infarction, 7 patients were hospitalized for revascularization, and 11 were medically treated for unstable angina. The annual cardiac event rate was 1.3% (0.78% in the first 3 years and 1.9% between the fourth and sixth years). The predictors of major adverse cardiac events in a multivariate analysis model were as follows: advanced age (hazard ratio [HR] 1.15, 95% confidence interval [95% CI] 1.02-1.30), diabetes (HR 17.5, 95% CI 2.2-140), and the habit of smoking (HR 5.9, 95% CI 1.0-35.5). For all causes of mortality, the only predictor was diabetes (HR 11.4, 95% CI 1.76-74.2). Patients with normal stress CMR had an excellent outcome during the 3 years after the study. The cardiac event rate was higher between the fourth and sixth years. CONCLUSION: Over a 5.5-year period, a low event rate and excellent prognosis occurred in patients with normal adenosine stress CMR. Low- to intermediate-risk patients with a normal CMR are at low risk for subsequent cardiac events.

Virtual calcium removal in calcified coronary arteries with photon-counting detector CT-first in-vivo experience.

Purpose: To evaluate the feasibility and accuracy of quantification of calcified coronary stenoses using virtual non-calcium (VNCa) images in coronary CT angiography (CCTA) with photon-counting detector (PCD) CT compared with quantitative coronary angiography (QCA). Materials and methods: This retrospective, institutional-review board approved study included consecutive patients with calcified coronary artery plaques undergoing CCTA with PCD-CT and invasive coronary angiography between July and December 2022. Virtual monoenergetic images (VMI) and VNCa images were reconstructed. Diameter stenoses were quantified on VMI and VNCa images by two readers. 3D-QCA served as the standard of reference. Measurements were compared using Bland-Altman analyses, Wilcoxon tests, and intraclass correlation coefficients (ICC). Results: Thirty patients [mean age, 64 years ± 8 (standard deviation); 26 men] with 81 coronary stenoses from calcified plaques were included. Ten of the 81 stenoses (12%) had to be excluded because of erroneous plaque subtraction on VNCa images. Median diameter stenosis determined on 3D-QCA was 22% (interquartile range, 11%-35%; total range, 4%-88%). As compared with 3D-QCA, VMI overestimated diameter stenoses (mean differences -10%, p < .001, ICC: .87 and -7%, p < .001, ICC: .84 for reader 1 and 2, respectively), whereas VNCa images showed similar diameter stenoses (mean differences 0%, p = .68, ICC: .94 and 1%, p = .07, ICC: .93 for reader 1 and 2, respectively). Conclusion: First experience in mainly minimal to moderate stenoses suggests that virtual calcium removal in CCTA with PCD-CT, when feasible, has the potential to improve the quantification of calcified stenoses.

Endoventricular circular patch repair: the "Dor procedure".

Although during recent decades the prompt clinical management of myocardial infarction has significantly reduced the incidence of mechanical complications, post-infarction heart failure is still an open issue. The surgical ventricular reconstruction technique, also called the "Dor procedure", was introduced as a surgical strategy to reduce left ventricular volume and restore its shape and function by performing an endoventricular circular patch plasty. Although its use was not clearly beneficial, there is growing evidence from specialized centres suggesting its safety and efficacy, thus bringing this technique back to a leading role in the surgical armamentarium to treat patients with heart failure. The objective of this work was to present a step-by-step explanation of the Dor procedure as a landmark for all surgeons who want to perform it.

Influence of Prolapse Volume in Mitral Valve Prolapse.

Mitral valve prolapse (MVP) is characterized by excessive leaflet tissue leading to a wide spectrum of mitral regurgitation (MR) ranging from trivial to severe. The prolapse volume (PV) below the prolapsing leaflets in end-systole was suspected to impact both chamber remodeling and MR grading in MVP. Based on 157 consecutive patients (45 women; mean age 62±15) referred for CMR assessment of MR, either from MVP (n = 91; 58%) or fibroelastic disease (FED) (n = 66; 42%), we sought to study (i) the interaction between PV and cardiac chamber geometry (ii) to study the impact of PV on MR quantification in MVP. Despite similar left ventricular (LV) size, PV was larger in MVP (11±9ml) than in FED (2±2ml). PV progressively increased with the severity of MR in MVP but not in FED. Despite a low regurgitant volume (32±18ml), some MVP patients with less than moderate MR exhibit significant cardiac chambers remodeling compared to 52 age and sex-matched controls. PV correlated significantly (r = 0.52) with the LV dilatation in severe MR but also in less than moderate MR. In MVP, PV>14ml was associated with a significant underestimation (Bias=-26±32ml) of regurgitant volume by PISA compared to CMR. In conclusion, in MVP, PV may play a role in left cardiac chambers remodeling, even in patients without severe MR, and in discordant grading of MR between echocardiography and CMR.

An Intravenous 100-mL Lipid Emulsion Infusion Dramatically Improves Myocardial Glucose Metabolism Extinction in Cardiac FDG PET Clinical Practice.

PURPOSE: Physiological myocardial accumulation of FDG impairs the diagnosis of inflammatory/infectious or tumoral myocardial detection by FDG PET/CT. We prospectively evaluated the addition, 3 hours before imaging, of an intravenous 100-mL lipid emulsion infusion (Intralipid) to a high-fat, low-carbohydrate diet (HFLCD) for at least 2 meals followed by a fast of at least 6 to 12 hours in patients referred for the diagnosis of myocardial inflammation, endocarditis, cardiac or paracardiac masses, intracardiac device, or prosthetic valve infections. METHODS: Data of 58 patients consecutively included (28 Intralipid patients, 30 controls with HFLCD alone) were compared. FDG uptake in normal myocardium was scored from 0 (complete myocardial suppression) to 3 (high diffuse uptake). Myocardial maximal, peak, and mean SUV and the rate of interpretable images according to the clinical indication were measured. RESULTS: Compared with controls, Intralipid infusion significantly improved the rate of score 0 (89% vs 63%, P = 0.021), of interpretable images according to the clinical indication (100% vs 72%, P = 0.0047) and decreased all myocardial SUV values (eg, SUVmax median, 1.9 [interquartile range, 1.7-2.5] vs 3.1 [interquartile range, 2.3-4.1]; P < 0.001). CONCLUSIONS: A lipid emulsion infusion in addition to HFLCD better suppresses cardiac glucose metabolism than HFLCD alone.

Non-contrast myocardial T1 global and regional reference values at 3 Tesla cardiac magnetic resonance in aortic stenosis.

BACKGROUND: T1 mapping using cardiac magnetic resonance (CMR) was recently proposed as a promising non-contrast imaging technique for the assessment of diffuse myocardial fibrosis (MF) in aortic stenosis (AS). AIMS: To provide reference values for native T1 mapping at 3 Tesla magnetic field strength in subjects with moderate or severe AS and in control subjects; to identify factors associated with the presence of diffuse MF in severe AS; to assess the regional distribution of diffuse MF; and to compare the level of diffuse MF in the different types of AS, stratified by flow and gradient patterns. METHODS: Retrospective study based on 160 consecutive patients with moderate (n=11) to severe (n=149) AS and 47 control subjects referred for CMR. RESULTS: Mean native T1 increased progressively across controls (1221±23ms), moderate AS (1249±26ms) and severe AS (1273±43ms). T1 times correlated significantly with left ventricular (LV) remodelling (indexed LV mass and LV diastolic volume) and functional LV alterations (global longitudinal strain and LV ejection fraction). Native T1 appears to be elevated in the basal segments of the septum in moderate AS, and to extend to midventricular and apical segments in severe AS. Mean T1 time was higher in classical low-flow/low-gradient AS (1295±62ms) than in the other types of AS (P=0.006). The level of diffuse MF in paradoxical low-flow/low-gradient AS (1280±42ms) was higher than in moderate AS, but similar to that in high-gradient AS (1271±42ms) (P=0.07). CONCLUSIONS: Assessment of diffuse MF in AS using T1 mapping is feasible and reproducible in clinical practice. T1 value increases with AS severity, along with morphological and functional LV alterations, particularly in the basal segments of the septum.

Usefulness of 3-Tesla Cardiac Magnetic Resonance to Detect Mitral Annular Disjunction in Patients With Mitral Valve Prolapse.

Mitral annulus disjunction (MAD) is characterized by a separation between the atrial wall mitral junction and the left ventricular (LV) free wall. Little is known regarding cardiac magnetic resonance (CMR) performance to detect MAD and its prevalence in mitral valve prolapse (MVP). Based on 89 MVP patients (63 women; mean age 64 ± 13) referred for CMR assessment of MR, either from myxomatous mitral valve disease (MMVP) (n = 40; 45%) or fibroelastic disease (n = 49; 55%), we sought to assess the frequency of MAD and its consequences on LV morphology. Patients were classified in 2 groups according to MAD presence (MAD+) or absence (MAD-). MAD (measuring 8 ± 4 mm) was diagnosed in 35% (31 of 89) of MVP patients, more frequently in MMVP than fibroelastic disease (60% vs 14%). MAD+ was associated with MMVP; bileaflet MVP and nonsustain ventricular tachycardia but not with the severity of MR. Diagnostic accuracy of transthoracic echocardiography for the detection of MAD was fair (65% sensitivity, 96% specificity) with CMR as reference. MAD+ showed significantly enlarged basal and mid LV diameters and enlarged mitral-annulus diameter. In patients with late gadolinium enhancement, presence of LV fibrosis at level of papillary muscle was more frequent in MAD+. After adjustment on age and MR severity, MMVP, and enlarged end-systolic mitral annulus diameter were independently associated with MAD+. In conclusion, MAD was present in about 1/3 of MVP patients, mostly in MMVP and independent of MR severity. Enlarged mitral-annulus and basal LV diameters, nonsustain ventricular tachycardia and papillary muscle fibrosis were associated with MAD presence.

Contrast-enhanced magnetic resonance imaging guided decision making after primary percutaneous coronary intervention for acute ST-elevation inferior myocardial infarction.

Coronary occlusion of large epicardial branches leads to profound ischemia at the infarct core, resulting in simultaneous necrosis of myocytes and endothelial cells. This process leads to microvascular obstruction in the infarct core, described as the no-reflow region in basic studies and documented in humans by contrast-enhanced magnetic resonance imaging and ultrasound. After coronary occlusion, contrast-enhanced magnetic resonance identifies myocardial infarction as a hyperenhanced region containing a hypoenhanced core. There is growing interest in incorporating its assessment into the evaluation of acute myocardial infarction because it is the key in defining specific therapeutic strategies and in directing the interventional therapy. We report a rare case of right ventricular infarction where contrast-enhanced magnetic resonance produced detailed images of myocardial perfusion pattern and tissue damage and directed the treatment after acute myocardial infarction.

Right-Sided Heart Structural and Functional Remodeling in Mitral Regurgitation Secondary to Mitral Valve Prolapse.

Preoperative evaluation of the mitral valve but also of tricuspid valve and right ventricular (RV) function is mandatory in primary mitral regurgitation (MR) secondary to mitral valve prolapse (MVP). Tricuspid annulus (TA) diameter plays a pivotal role in the surgical decision to perform preventive combined tricuspid valve annuloplasty. Cardiac magnetic resonance (CMR) is the gold standard for the assessment of RV size and function. Based on 70 consecutive patients (17 women; mean age 64 ± 12) with severe MR secondary to MVP referred for CMR, we sought to assess RV geometry and function and TA dimensions and to study the interaction between TA dilatation and right-sided cardiac chambers. Frequency of RV dilatation, RV systolic dysfunction, and TA dilatation (TA diameter ≥ 40 or 21 mm/m²) were 11%, 51%, and 49%, respectively. Left ventricular (LV) end-diastolic volume index was the only independent predictor of RV dilatation. Presence of symptoms, larger LV end-diastolic volume index, and LV ejection fraction <60% were independently associated with RV dysfunction. Absolute TA diameter was 36 ± 6 mm and TA diameter index was 20 ± 3 mm/m². Reproducibility TA diameter measurement was excellent (coefficient of variation ≤10%). TR velocity >220 cm/s (odds ratio = 20.17; [3.57 to 113.90]; p = 0.001 and right atrial volume index ≥ 38 ml/m² (odds ratio = 13.44; [3.57 to 50.54]; p = 0.0001) were independent predictors of TA diameter ≥40 or 21 mm/m². CMR provides accurate right-sided cardiac chambers assessment and may help surgical planning of concomitant tricuspid valve annuloplasty before mitral valve repair in severe MR secondary to MVP. In conclusion, TA dilatation, RV enlargement, and dysfunction are related to pulmonary pressure and left-sided cardiac chambers enlargement, reflecting the long-standing consequences of severe MR.

Performance of new automated transthoracic three-dimensional echocardiographic software for left ventricular volumes and function assessment in routine clinical practice: Comparison with 3 Tesla cardiac magnetic resonance.

BACKGROUND: Three-dimensional (3D) transthoracic echocardiography (TTE) is superior to two-dimensional Simpson's method for assessment of left ventricular (LV) volumes and LV ejection fraction (LVEF). Nevertheless, 3D TTE is not incorporated into everyday practice, as current LV chamber quantification software products are time-consuming. AIMS: To evaluate the feasibility, accuracy and reproducibility of new fully automated fast 3D TTE software (HeartModelA.I.; Philips Healthcare, Andover, MA, USA) for quantification of LV volumes and LVEF in routine practice; to compare the 3D LV volumes and LVEF obtained with a cardiac magnetic resonance (CMR) reference; and to optimize automated default border settings with CMR as reference. METHODS: Sixty-three consecutive patients, who had comprehensive 3D TTE and CMR examinations within 24hours, were eligible for inclusion. Nine patients (14%) were excluded because of insufficient echogenicity in the 3D TTE. Thus, 54 patients (40 men; mean age 63±13 years) were prospectively included into the study. RESULTS: The inter- and intraobserver reproducibilities of 3D TTE were excellent (coefficient of variation<10%) for end-diastolic volume (EDV), end-systolic volume (ESV) and LVEF. Despite a slight underestimation of EDV using 3D TTE compared with CMR (bias=-22±34mL; P<0.0001), a significant correlation was found between the two measurements (r=0.93; P=0.0001). Enlarging default border detection settings leads to frequent volume overestimation in the general population, but improved agreement with CMR in patients with LVEF≤50%. Correlations between 3D TTE and CMR for ESV and LVEF were excellent (r=0.93 and r=0.91, respectively; P<0.0001). CONCLUSION: 3D TTE using new-generation fully automated software is a feasible, fast, reproducible and accurate imaging modality for LV volumetric quantification in routine practice. Optimization of border detection settings may increase agreement with CMR for EDV assessment in dilated ventricles.

Usefulness of 3-Tesla cardiac magnetic resonance imaging in the assessment of aortic stenosis severity in routine clinical practice.

BACKGROUND: Recently, 1.5-Tesla cardiac magnetic resonance imaging (CMR) was reported to provide a reliable alternative to transthoracic echocardiography (TTE) for the quantification of aortic stenosis (AS) severity. Few data are available using higher magnetic field strength MRI systems in this context. AIMS: To evaluate the feasibility and reproducibility of the assessment of aortic valve area (AVA) using 3-Tesla CMR in routine clinical practice, and to assess concordance between TTE and CMR for the estimation of AS severity. METHODS: Ninety-one consecutive patients (60 men; mean age 74±10years) with known AS documented by TTE were included prospectively in the study. RESULTS: All patients underwent comprehensive TTE and CMR examination, including AVA estimation using the TTE continuity equation (0.81±0.18cm2), direct CMR planimetry (CMRp) (0.90±0.22cm2) and CMR using Hakki's formula (CMRhk), a simplified Gorlin formula (0.70±0.19cm2). Although significant agreement with TTE was found for CMRp (r=0.72) and CMRhk (r=0.66), CMRp slightly overestimated (bias=0.11±0.18cm2) and CMRhk slightly underestimated (bias=-0.11±0.17cm2) AVA compared with TTE. Inter- and intraobserver reproducibilities of CMR measurements were excellent (r=0.72 and r=0.74 for CMRp and r=0.88 and r=0.92 for peak aortic velocity, respectively). CONCLUSION: 3-Tesla CMR is a feasible, radiation-free, reproducible imaging modality for the estimation of severity of AS in routine practice, knowing that CMRp tends to overestimate AVA and CMRhk to underestimate AVA compared with TTE.