Can transthoracic echocardiography be used to a greater extent in the diagnostics of infective endocarditis to avoid unnecessary transoesophageal examinations without jeopardising accuracy?

BACKGROUND: Infective endocarditis (IE) is a serious condition that requires prompt diagnosis and treatment. Transthoracic echocardiography (TTE) is usually the initial imaging modality, however transoesophageal echocardiography (TOE) is sometimes necessary because of its higher sensitivity for IE. Yet, TOE may imply an increased risk of complications. This project aims to evaluate whether TTE can be used to a greater extent in the diagnostics of IE to avoid unnecessary TOE examinations without jeopardizing diagnostic accuracy. METHODS: Data from all TOE examinations performed on patients hospitalized with clinical suspicion of IE between 2019-05-01 and 2020-04-30 at a university hospital in Stockholm, Sweden, were obtained and analysed. Variables included for analysis were age, sex, blood culture results, aetiology, results from TOE, number of TOEs during the inclusion period, results from positron emission tomography/computed tomography (PET/CT), new regurgitation, cardiac murmur, previous IE, prosthetic valve, predisposing factors, i.e. cardiac comorbidities, injection drug use, fever, vascular phenomena, and immunological phenomena. To assess associations between predisposing factors or aetiology of IE and TOE findings, chi square tests and logistic regression models were used. For continuous variables, linear regression was used for comparisons of means and quantile regression was used for comparisons of medians. P < 0.05 was considered significant. RESULTS: In total 195 TOE examinations (Table 1) from 160 patients were included, of which 61 (31%) were positive for IE. In total, 36 examinations had negative TTE prior to TOE of which 32 (86%) also had negative TOE. Of the 5 (14%) negative TTE prior to TOE that had positive TOE, all had cardiovascular implantable electronic device (CIED) and/or prosthetic valves. CONCLUSIONS: The existing recommendations for TOE in patients with clinical suspicion of IE are probably broad enough not to miss patients with IE, but there might be an unnecessarily large number of patients being referred for TOE with negative results. Negative TTE examination with good image quality and no CIED or prosthetic valves, may be sufficient without jeopardizing the IE diagnosis.

Thrombosis and Bleeding After Implementation of an Intermediate-Dose Prophylactic Anticoagulation Protocol in ICU Patients With COVID-19: A Multicenter Screening Study.

Thrombosis and bleeding after implementation of an intermediate-dose prophylactic anticoagulation protocol in intensive care unit (ICU) patients with coronavirus disease 2019 (COVID-19): a multicenter screening study Background: Venous thromboembolism (VTE) is common among critically ill patients with COVID-19. Information regarding VTE prevalence and bleeding complications after implementation of intermediate-dose prophylactic anticoagulation in such patients is, however, limited. Methods: We performed a prospective, observational study in 6 ICUs in 2 university-affiliated teaching hospitals in Sweden. After implementation of an intermediate-dose prophylactic anticoagulation protocol, we performed ultrasound screening for proximal lower-extremity deep vein thrombosis (DVT) and collected routine computed tomography pulmonary angiography exam results. Results: A total of 100 COVID-19 patients were included from June 21, 2020, through February 18, 2021. During a median follow-up of 120 (IQR, 89-134) days, we found VTE in 37 patients with the majority (78.4%) being diagnosed after ICU arrival. Overall, 20 patients had proximal lower-extremity DVT with 95% being detected on ultrasound screening; 22 patients had pulmonary vascular thrombosis; and 4 patients had venous thrombosis at other sites. A total of 6 patients had both proximal lower-extremity DVT and pulmonary vascular thrombosis. On univariate logistic regression analysis of 14 baseline characteristics, only pre-existing heart failure was associated with VTE (OR 4.67, 95% CI 1.13-19.34). Major and non-major bleeding occurred in 10 and 18 patients, respectively. Conclusions: In our cohort of ICU patients with COVID-19, we observed a high prevalence of VTE and bleeding complications after implementation of intermediate-dose anticoagulation. In approximately half of patients, VTE was identified on screening ultrasound.

Moderately trained male football players, compared to sedentary male adults, exhibit anatomical but not functional cardiac remodelling, a cross-sectional study.

BACKGROUND: Elite athletes have been the subject of great interest, but athletes at an intermediate level of physical activity have received less attention in respect to the presence of cardiac enlargement and/or hypertrophy. We hypothesized that playing football, often defined as demanding less endurance components than running or cycling, would still induce remodelling similar to sports with a dominating endurance component. METHODS: 23 male football players, age 25+/- 3.9 yrs. underwent exercise testing, 2D- and 3D- echocardiography and cardiac magnetic resonance (CMR). The results were compared with a control group of engineering students of similar age. The athletes exercised 12 h/week and the control subjects 1 h/week, p < 0.001. RESULTS: The football players achieved a significantly higher maximal load at the exercise test (380 W vs 300 W, p < 0.001) as well as higher calculated maximal oxygen consumption, (49.7 vs 37.4 mL x kg- 1 x min- 1, p < 0.001) compared to the sedentary group. All left ventricular (LV) volumes assessed by 3DEcho and CMR, as well as CMR left atrial (LA) volume were significantly higher in the athletes (3D-LVEDV 200 vs 154 mL, CMR-LVEDV 229 vs 185 mL, CMR-LA volume 100 vs 89 mL, p < 0.001, p = 0.002 and p = 0.009 respectively). LVEF and RVEF, LV strain by CMR or by echo did not differentiate athletes from sedentary participants. Right ventricular (RV) longitudinal strain, LA and right atrial (RA) strain by CMR all showed similar results in the two groups. CONCLUSION: Moderately trained intermediate level football players showed anatomical but not functional cardiac remodelling compared to sedentary males.

Active chest tube clearance after aortic valve surgery did not influence amount residual pericardial fluid after aortic valve replacement in a randomised trial.

Objective. Evaluate if the use of active clearance of chest tubes after aortic valve surgery influenced bleeding and reduced postoperative residual pericardial effusion. Design. Prospective randomised trial comparing PleuraFlow® 32 F chest tube with FlowGlide™ active clearance to a standard Argyle® 32 F chest tube in 100 patients undergoing aortic valve surgery. Chest tube outputs and pericardial effusion measurements assessed by two-dimensional transthoracic echocardiography were recorded before hospital discharge. Results. Postoperative chest tube outputs per hour did not differ between the two groups. The median chest tube output was 400 mL for patients who had a PleuraFlow® chest tube vs. 490 mL for patients with an Argyle® chest tube (p = .08). Pericardial effusions ≥ 2 mm were detected in 76% vs. 68% of the patients (p = .50) and postoperative atrial fibrillation occurred in 42% vs. 34% (p = .54), respectively. Conclusions. Use of active clearance chest tubes, compared to standard chest tubes after aortic valve surgery did not differ significantly regarding postoperative bleeding or degree of pericardial effusion as measured by echocardiography prior to hospital discharge.

Cardiovascular magnetic resonance 4D flow analysis has a higher diagnostic yield than Doppler echocardiography for detecting increased pulmonary artery pressure.

BACKGROUND: Pulmonary hypertension is definitively diagnosed by the measurement of mean pulmonary artery (PA) pressure (mPAP) using right heart catheterization. Cardiovascular magnetic resonance (CMR) four-dimensional (4D) flow analysis can estimate mPAP from blood flow vortex duration in the PA, with excellent results. Moreover, the peak systolic tricuspid regurgitation (TR) pressure gradient (TRPG) measured by Doppler echocardiography is commonly used in clinical routine to estimate systolic PA pressure. This study aimed to compare CMR and echocardiography with regards to quantitative and categorical agreement, and diagnostic yield for detecting increased PA pressure. METHODS: Consecutive clinically referred patients (n = 60, median [interquartile range] age 60 [48-68] years, 33% female) underwent echocardiography and CMR at 1.5 T (n = 43) or 3 T (n = 17). PA vortex duration was used to estimate mPAP using a commercially available time-resolved multiple 2D slice phase contrast three-directional velocity encoded sequence covering the main PA. Transthoracic Doppler echocardiography was performed to measure TR and derive TRPG. Diagnostic yield was defined as the fraction of cases in which CMR or echocardiography detected an increased PA pressure, defined as vortex duration ≥15% of the cardiac cycle (mPAP ≥25 mmHg) or TR velocity > 2.8 m/s (TRPG > 31 mmHg). RESULTS: Both CMR and echocardiography showed normal PA pressure in 39/60 (65%) patients and increased PA pressure in 9/60 (15%) patients, overall agreement in 48/60 (80%) patients, kappa 0.49 (95% confidence interval 0.27-0.71). CMR had a higher diagnostic yield for detecting increased PA pressure compared to echocardiography (21/60 (35%) vs 9/60 (15%), p < 0.001). In cases with both an observable PA vortex and measurable TR velocity (34/60, 56%), TRPG was correlated with mPAP (R2 = 0.65, p < 0.001). CONCLUSIONS: There is good quantitative and fair categorical agreement between estimated mPAP from CMR and TRPG from echocardiography. CMR has higher diagnostic yield for detecting increased PA pressure compared to echocardiography, potentially due to a lower sensitivity of echocardiography in detecting increased PA pressure compared to CMR, related to limitations in the ability to adequately visualize and measure the TR jet by echocardiography. Future comparison between echocardiography, CMR and invasive measurements are justified to definitively confirm these findings.

The dynamics of extracellular gadolinium-based contrast agent excretion into pleural and pericardial effusions quantified by T1 mapping cardiovascular magnetic resonance.

INTRODUCTION: Excretion of cardiovascular magnetic resonance (CMR) extracellular gadolinium-based contrast agents (GBCA) into pleural and pericardial effusions, sometimes referred to as vicarious excretion, has been described as a rare occurrence using T1-weighted imaging. However, the T1 mapping characteristics as well as presence, magnitude and dynamics of contrast excretion into these effusions is not known. AIMS: To investigate and compare the differences in T1 mapping characteristics and extracellular GBCA excretion dynamics in pleural and pericardial effusions. METHODS: Clinically referred patients with a pericardial and/or pleural effusion underwent CMR T1 mapping at 1.5 T before, and at 3 (early) and at 27 (late) minutes after administration of an extracellular GBCA (0.2 mmol/kg, gadoteric acid). Analyzed effusion characteristics were native T1, ΔR1 early and late after contrast injection, and the effusion-volume-independent early-to-late contrast concentration ratio ΔR1early/ΔR1late, where ΔR1 = 1/T1post-contrast - 1/T1native. RESULTS: Native T1 was lower in pericardial effusions (n = 69) than in pleural effusions (n = 54) (median [interquartile range], 2912 [2567-3152] vs 3148 [2692-3494] ms, p = 0.005). Pericardial and pleural effusions did not differ with regards to ΔR1early (0.05 [0.03-0.10] vs 0.07 [0.03-0.12] s- 1, p = 0.38). Compared to pleural effusions, pericardial effusions had a higher ΔR1late (0.8 [0.6-1.2] vs 0.4 [0.2-0.6] s- 1, p < 0.001) and ΔR1early/ΔR1late (0.19 [0.08-0.30] vs 0.12 [0.04-0.19], p < 0.001). CONCLUSIONS: T1 mapping shows that extracellular GBCA is excreted into pericardial and pleural effusions. Consequently, the previously used term vicarious excretion is misleading. Compared to pleural effusions, pericardial effusions had both a lower native T1, consistent with lesser relative fluid content in relation to other components such as proteins, and more prominent early excretion dynamics, which could be related to inflammation. The clinical diagnostic utility of T1 mapping to determine quantitative contrast dynamics in pericardial and pleural effusions merits further investigation.

Positive effect on patient experience of video information given prior to cardiovascular magnetic resonance imaging: A clinical trial.

AIMS AND OBJECTIVES: To evaluate the effect of video information given before cardiovascular magnetic resonance imaging on patient anxiety and to compare patient experiences of cardiovascular magnetic resonance imaging versus myocardial perfusion scintigraphy. To evaluate whether additional information has an impact on motion artefacts. BACKGROUND: Cardiovascular magnetic resonance imaging and myocardial perfusion scintigraphy are technically advanced methods for the evaluation of heart diseases. Although cardiovascular magnetic resonance imaging is considered to be painless, patients may experience anxiety due to the closed environment. DESIGN: A prospective randomised intervention study, not registered. METHODS: The sample (n = 148) consisted of 97 patients referred for cardiovascular magnetic resonance imaging, randomised to receive either video information in addition to standard text-information (CMR-video/n = 49) or standard text-information alone (CMR-standard/n = 48). A third group undergoing myocardial perfusion scintigraphy (n = 51) was compared with the cardiovascular magnetic resonance imaging-standard group. Anxiety was evaluated before, immediately after the procedure and 1 week later. Five questionnaires were used: Cardiac Anxiety Questionnaire, State-Trait Anxiety Inventory, Hospital Anxiety and Depression scale, MRI Fear Survey Schedule and the MRI-Anxiety Questionnaire. Motion artefacts were evaluated by three observers, blinded to the information given. Data were collected between April 2015-April 2016. The study followed the CONSORT guidelines. RESULT: The CMR-video group scored lower (better) than the cardiovascular magnetic resonance imaging-standard group in the factor Relaxation (p = .039) but not in the factor Anxiety. Anxiety levels were lower during scintigraphic examinations compared to the CMR-standard group (p < .001). No difference was found regarding motion artefacts between CMR-video and CMR-standard. CONCLUSION: Patient ability to relax during cardiovascular magnetic resonance imaging increased by adding video information prior the exam, which is important in relation to perceived quality in nursing. No effect was seen on motion artefacts. RELEVANCE TO CLINICAL PRACTICE: Video information prior to examinations can be an easy and time effective method to help patients cooperate in imaging procedures.

Spontaneous coronary artery dissection and takotsubo syndrome: The chicken or the egg causality dilemma.

Acute coronary syndrome (ACS) including spontaneous coronary artery dissection (SCAD) has been reported to trigger its own clinical twin takotsubo syndrome (TS). The pathogenetic association between SCAD and TS remains to be elucidated. The two diseases afflict predominantly women and both conditions may be triggered by an emotional stress factor and an unusual extreme physical exercise. Herein, we describe a case of 54-year-old woman presenting with ACS caused by an obtuso-marginal SCAD. Concurrently, the patient had typical clinical features and course of mid-apical pattern of TS. The causal link between the two conditions is discussed. © 2017 Wiley Periodicals, Inc.

Development and validation of a questionnaire evaluating patient anxiety during Magnetic Resonance Imaging: the Magnetic Resonance Imaging-Anxiety Questionnaire (MRI-AQ).

AIM: To develop and validate a new instrument measuring patient anxiety during Magnetic Resonance Imaging examinations, Magnetic Resonance Imaging- Anxiety Questionnaire. BACKGROUND: Questionnaires measuring patients' anxiety during Magnetic Resonance Imaging examinations have been the same as used in a wide range of conditions. To learn about patients' experience during examination and to evaluate interventions, a specific questionnaire measuring patient anxiety during Magnetic Resonance Imaging is needed. DESIGN: Psychometric cross-sectional study with test-retest design. METHODS: A new questionnaire, Magnetic Resonance Imaging-Anxiety Questionnaire, was designed from patient expressions of anxiety in Magnetic Resonance Imaging-scanners. The sample was recruited between October 2012-October 2014. Factor structure was evaluated with exploratory factor analysis and internal consistency with Cronbach's alpha. Criterion-related validity, known-group validity and test-retest was calculated. RESULTS: Patients referred for Magnetic Resonance Imaging of either the spine or the heart, were invited to participate. The development and validation of Magnetic Resonance Imaging-Anxiety Questionnaire resulted in 15 items consisting of two factors. Cronbach's alpha was found to be high. Magnetic Resonance Imaging-Anxiety Questionnaire correlated higher with instruments measuring anxiety than with depression scales. Known-group validity demonstrated a higher level of anxiety for patients undergoing Magnetic Resonance Imaging scan of the heart than for those examining the spine. Test-retest reliability demonstrated acceptable level for the scale. CONCLUSION: Magnetic Resonance Imaging-Anxiety Questionnaire bridges a gap among existing questionnaires, making it a simple and useful tool for measuring patient anxiety during Magnetic Resonance Imaging examinations.

Phase analysis detects heterogeneity of myocardial deformation on cine MRI.

OBJECTIVES: Myocardial scar will lead to heterogeneous left ventricular deformation. We hypothesized that a myocardial scar will display an elevated standard deviation (SD) of phase and that this effect could be compared with mechanical dispersion. DESIGN: Thirty patients (three women and 27 men) were investigated over 4-8 weeks after ST-elevation myocardial infarction treated with percutaneous coronary intervention. Seventeen had a scar area > 75% in at least one antero- or inferoseptal segment (scar) and 13 had a scar area < 1% (non-scar). The phase delays of velocity, displacement, and strain were measured in the longitudinal direction, tangential to the endocardial outline, and in the radial direction, perpendicular to the tangent. RESULTS: The SD of phase in radial measurements differentiated scar patients from those without scar (p < 0.01), while longitudinal measurements did so only for longitudinal strain. Likewise, the SD for radial measurements of time to peak for segmental velocity, displacement, and strain performed better than longitudinal measurements and equal to the results of phase. CONCLUSION: Phase dispersion in deformation imaging may be used for detecting heterogeneous left ventricular contraction.

Cardiac biopsies reveal differences in transcriptomics between left and right ventricle in patients with or without diagnostic signs of heart failure.

New or mild heart failure (HF) is mainly caused by left ventricular dysfunction. We hypothesised that gene expression differ between the left (LV) and right ventricle (RV) and secondly by type of LV dysfunction. We compared gene expression through myocardial biopsies from LV and RV of patients undergoing elective coronary bypass surgery (CABG). Patients were categorised based on LV ejection fraction (EF), diastolic function and NT-proBNP into pEF (preserved; LVEF ≥ 45%), rEF (reduced; LVEF < 45%) or normal LV function. Principal component analysis of gene expression displayed two clusters corresponding to LV and RV. Up-regulated genes in LV included natriuretic peptides NPPA and NPPB, transcription factors/coactivators STAT4 and VGLL2, ion channel related HCN2 and LRRC38 associated with cardiac muscle contraction, cytoskeleton, and cellular component movement. Patients with pEF phenotype versus normal differed in gene expression predominantly in LV, supporting that diastolic dysfunction and structural changes reflect early LV disease in pEF. DKK2 was overexpressed in LV of HFpEF phenotype, potentially leading to lower expression levels of ß-catenin, α-SMA (smooth muscle actin), and enhanced apoptosis, and could be a possible factor in the development of HFpEF. CXCL14 was down-regulated in both pEF and rEF, and may play a role to promote development of HF.

Four- to seven-year follow-up of pharmacological postconditioning with mangafodipir as an adjunct to primary PCI in ST-segment elevation myocardial infarction.

INTRODUCTION: Adverse left ventricular remodelling (AR) develops over time in approximately 30% of patients with a history of coronary artery disease. AR manifests as a structural change in the left ventricle (LV) in terms of increased volumes and reduced left ventricular ejection fraction (LVEF). Manganese dipyridoxyl diphosphate (mangafodipir) has demonstrated interesting cardioprotective features in acute myocardial ischaemia. Pharmacological postconditioning (PP) with mangafodipir as an adjunct to primary percutaneous coronary intervention may possibly reduce the development of AR over time in ST-elevation myocardial infarction (STEMI). The aim of this 4-7-year follow-up study is to investigate the potential benefits of PP with mangafodipir in STEMI patients. METHOD: Thirteen out of the initial 20 patients that were included in the primary study of Karlsson et al. were followed up between April and June 2017. The study group underwent review of the hospital records, a clinical examination with ECG and blood sample analysis before cardiac magnetic resonance examination of the patient. LVEF, left ventricular diastolic volume, left ventricular end systolic volume, LV mass and myocardial strain in all directions were computed. RESULTS: The PP group showed a decrease in LV volume, mass and higher LVEF at follow-up (p < 0.05) while the individual response of the placebo group showed features that are seen in AR. Although there was no difference in myocardial strain, measurement for the PP-group was higher in absolute terms. CONCLUSION: Pharmacological postconditioning with mangafodipir in STEMI demonstrated cardioprotective features compared to the placebo group at follow-up. This article is protected by copyright. All rights reserved.

Health-related quality-of-life up to one year after myocardial infarction with non-obstructive coronary arteries.

AIMS: Patients with Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) are a heterogenous group and previous studies indicate a decreased Health-related quality-of-life (HRQoL) compared with patients with myocardial infarction with obstructive coronary artery disease and healthy individuals. However, longitudinal data are scarce. Therefore, the aim was to explore HRQoL among patients with MINOCA during a one-year period after the acute event in comparison with a group of healthy individuals and to describe HRQoL in patients with Takotsubo Syndrome (TTS). METHODS AND RESULTS: Patients with MINOCA were recruited from five hospitals in the Stockholm region (SMINC-2 study, clinical trials: NCT2318498). Patients responded to the HRQoL questionnaire RAND-36 between days 2-4, after 6 and 12 months respectively. A sample of population-based individuals was used as a comparison group. A total of 142 MINOCA patients, (70% women) mean age of 56 years, responded. A population-based sample of 317 volunteers (66% women) mean age of 57 years. Patients with MINOCA scored lower than the comparison group in the domains role functioning physical, social functioning, and role functioning emotional (P = 0.01-0.02) at 12 months. In these domains of HRQoL there was no improvement in MINOCA patients during 12 months follow-up. In the domains of energy/fatigue vitality and emotional well-being the scores improved and were similar to the comparison group at 12 months. Patients with TTS scored generally lower on RAND-36 than MINOCA patients without TTS. CONCLUSION: Physical, social, and emotional functioning did not improve during the first year after MINOCA, indicating a need for increased follow-up including psychological support.

Reduced Pulmonary Artery Distensibility Predicts Persistent Pulmonary Hypertension and 2-Year Mortality in Patients with Severe Aortic Stenosis Undergoing TAVR.

RATIONALE AND OBJECTIVES: Post-TAVR persistent pulmonary hypertension (PH) is a better predictor of poor outcome than pre-TAVR PH. In this longitudinal study we sought to evaluate whether pulmonary artery (distensibility (DPA) measured on preprocedural ECG-gated CTA is associated with persistent-PH and 2-year mortality after TAVR. MATERIALS AND METHODS: Three hundred and thirty-six patients undergoing TAVR between July 2012 and March 2016 were retrospectively included and followed for all-cause mortality until November 2017. All patients underwent retrospectively ECG-gated CTA prior to TAVR. Main pulmonary artery (MPA) area was measured in systole and in diastole. DPA was calculated as: [(area-MPAmax-area-MPAmin)/area-MPAmax]%. ROC analysis was performed to assess the AUC for persistent-PH. Youden Index was used to determine the optimal threshold of DPA for persistent-PH. Two groups were compared based on a DPA threshold of 8% (specificity of 70% for persistent-PH). Kaplan-Meier, Cox proportional-hazard, and logistic regression analyses were performed. The primary clinical endpoint was defined as persistent-PH post-TAVR. The secondary endpoint was defined as all-cause mortality 2 years after TAVR. RESULTS: Median follow-up time was 413 (interquartiles 339-757) days. A total of 183 (54%) had persistent-PH and 68 (20%) patients died within 2-years after TAVR. Patients with DPA<8% had significantly more persistent-PH (67% vs 47%, p<0.001) and 2-year deaths (28% vs 15%, p=0.006), compared to patients with DPA>8%. Adjusted multivariable regression analyses showed that DPA<8% was independently associated with persistent-PH (OR 2.10 [95%-CI 1.3-4.5], p=0.007) and 2-year mortality (HR 2.91 [95%-CI 1.5-5.8], p=0.002). Kaplan-Meier analysis showed that 2-year mortality of patients with DPA<8% was significantly higher compared to patients with DPA≥8% (mortality 28% vs 15%; log-rank p=0.003). CONCLUSION: DPA on preprocedural CTA is independently associated with persistent-PH and two-year mortality in patients who undergo TAVR.

Prognostic utility and characterization of left ventricular hypertrophy using global thickness.

Cardiovascular magnetic resonance (CMR) can accurately measure left ventricular (LV) mass, and several measures related to LV wall thickness exist. We hypothesized that prognosis can be used to select an optimal measure of wall thickness for characterizing LV hypertrophy. Subjects having undergone CMR were studied (cardiac patients, n = 2543; healthy volunteers, n = 100). A new measure, global wall thickness (GT, GTI if indexed to body surface area) was accurately calculated from LV mass and end-diastolic volume. Among patients with follow-up (n = 1575, median follow-up 5.4 years), the most predictive measure of death or hospitalization for heart failure was LV mass index (LVMI) (hazard ratio (HR)[95% confidence interval] 1.16[1.12-1.20], p < 0.001), followed by GTI (HR 1.14[1.09-1.19], p < 0.001). Among patients with normal findings (n = 326, median follow-up 5.8 years), the most predictive measure was GT (HR 1.62[1.35-1.94], p < 0.001). GT and LVMI could characterize patients as having a normal LV mass and wall thickness, concentric remodeling, concentric hypertrophy, or eccentric hypertrophy, and the three abnormal groups had worse prognosis than the normal group (p < 0.05 for all). LV mass is highly prognostic when mass is elevated, but GT is easily and accurately calculated, and adds value and discrimination amongst those with normal LV mass (early disease).

Relationship between treatment delay and final infarct size in STEMI patients treated with abciximab and primary PCI.

BACKGROUND: Studies on the impact of time to treatment on myocardial infarct size have yielded conflicting results. In this study of ST-Elevation Myocardial Infarction (STEMI) treated with primary percutaneous coronary intervention (PCI), we set out to investigate the relationship between the time from First Medical Contact (FMC) to the demonstration of an open infarct related artery (IRA) and final scar size.Between February 2006 and September 2007, 89 STEMI patients treated with primary PCI were studied with contrast enhanced magnetic resonance imaging (ceMRI) 4 to 8 weeks after the infarction. Spearman correlation was computed for health care delay time (defined as time from FMC to PCI) and myocardial injury. Multiple linear regression was used to determine covariates independently associated with infarct size. RESULTS: An occluded artery (Thrombolysis In Myocardial Infarction, TIMI flow 0-1 at initial angiogram) was seen in 56 patients (63%). The median FMC-to-patent artery was 89 minutes. There was a weak correlation between time from FMC-to-patent IRA and infarct size, r = 0.27, p = 0.01. In multiple regression analyses, LAD as the IRA, smoking and an occluded vessel at the first angiogram, but not delay time, correlated with infarct size. CONCLUSIONS: In patients with STEMI treated with primary PCI we found a weak correlation between health care delay time and infarct size. Other factors like anterior infarction, a patent artery pre-PCI and effects of reperfusion injury may have had greater influence on infarct size than time-to-treatment per se.

[Cosmetic breast implants can influence cardiac imaging]. / Bröstimplantat kan försvåra diagnostik av hjärtsjukdomar.

Cosmetic breast implants are increasing in popularity. The presence of foreign material overlying the anterior wall of the heart can influence cardiac imaging and lead to misdiagnosis of cardiac disease.  Echocardiography is commonly used in patients for evaluation of cardiac structure and function. Breast implants can cause impaired quality of the echocardiographic images because of an interaction between the implant material and the ultrasound beam, and as a consequence this can lead to a decreased diagnostic accuracy. In myocardial perfusion imaging breast implant can induce attenuation artifacts, which can be mistaken for myocardial infarction. The number of indications for cardiac MRI examinations are increasing, but also with this technique the presence of breast implants can induce artefacts that impair the possibilities to optimal quality. Women considering breast augmentation should be informed of the risk that the procedure can result in impaired quality of different cardiac imaging modalities.

Evaluation of left ventricular diastolic function in patients operated for aortic stenosis.

BACKGROUND: Left ventricular diastolic dysfunction is common in patients with aortic valve stenosis (AS) and reportedly affects prognosis after surgical aortic valve replacement (SAVR). Here we investigated whether and how diastolic function (assessed following the most recent guidelines) was affected by SAVR, and whether preoperative diastolic function affected postoperative outcome. We also examined whether long-term mortality was associated with preoperative NT-proBNP and postoperative heart failure (PHF). METHODS: We performed a prospective observational study of 273 patients with AS who underwent AVR with or without concomitant coronary artery bypass surgery. Of these patients, 247 were eligible for assessment of left ventricular (LV) filling pressure. Preoperatively and at the 6-month postoperative follow-up, we measured N-terminal pro-B type natriuretic peptide (NT-proBNP) in serum and assessed diastolic function with Doppler echocardiography. PHF was diagnosed using prespecified criteria. Multivariable logistic regression was performed to explore variables associated with high LV filling pressure. Cox regression was performed to explore variables associated with mortality, accounting for timeto-event. RESULTS: At the time of surgery, 22% (n = 54) of patients had diastolic dysfunction expressed as high LV filling pressure. Of these 54 patients, 27 (50%) showed postoperative diastolic function improvement. Among the 193 patients with preoperative low LV filling pressure, 24 (12%) showed postoperative diastolic function deterioration. Increased long-term mortality was associated with PHF and high preoperative NT-proBNP, but not with preoperative or postoperative diastolic dysfunction. Cox regression revealed the following independent risk factors for long-term mortality: diabetes, renal dysfunction, preoperative NT-proBNP>960 ng/L, age, and male gender. CONCLUSIONS: Surgery for aortic stenosis improved diastolic function in patients with high LV filling pressure in 50% of the patients. Our results could not confirm the previously suggested role of diastolic dysfunction as a marker for poor long-term survival after SAVR. Our findings showed that both PHF and high preoperative NT-proBNP were associated with long-term mortality.

Diffusely Increased Myocardial Extracellular Volume With or Without Focal Late Gadolinium Enhancement: Prevalence and Associations With Left Ventricular Size and Function.

PURPOSE: Myocardial extracellular volume fraction (ECV) using cardiovascular magnetic resonance (CMR) can identify diffuse lesions not detected by late gadolinium enhancement (LGE). We aimed to determine the prevalence of increased ECV and its relation to other CMR findings. MATERIALS AND METHODS: Consecutive patients (n=609, age median [interquartile range] 53 [39 to 66] y, 62% male) underwent CMR at 1.5 T. Focal lesions on LGE images were noted. ECV in regions without focal LGE findings defined diffuse changes. Pronounced increases in left ventricular (LV) end-diastolic volume index and LV mass index, and pronounced decreases in LV ejection fraction were defined as >3 SD from the sex-specific mean in healthy volunteers. RESULTS: Of 609 patients without amyloidosis or hypertrophic cardiomyopathy, 8% had diffusely increased ECV and 5% of all patients had diffusely increased ECV without any focal LGE findings. Multivariate analysis showed that a pronounced increase in the LV end-diastolic volume index was associated with increased ECV (P=0.001), but not LGE (P=0.52). A pronounced decrease in LV ejection fraction was associated with the presence of LGE (P<0.001), but not with increased ECV (P=0.41). CONCLUSIONS: Eight percent of patients in this clinical cohort with known or suspected heart disease had diffusely increased ECV and 60% of these lacked focal LGE findings. LV size is independently associated with increased ECV, whereas systolic dysfunction is independently associated with LGE. This image-based clinical study demonstrates that ECV-CMR provides additional information negligibly related to the results of LGE imaging, and thereby increases the diagnostic yield of CMR.

Baseline characteristics of 547 new onset heart failure patients in the PREFERS heart failure study.

AIM: We present the baseline characteristics of the PREFERS Stockholm epidemiological study on the natural history and course of new onset heart failure (HF) aiming to improve phenotyping focusing on HF with preserved left ventricular ejection fraction (HFpEF) pathophysiology. METHODS AND RESULTS: New onset HF patients diagnosed in hospital or at outpatient HF clinics were included at five Stockholm hospitals 2015-2018 and characterized by N-terminal pro brain natriuretic peptide (NT-proBNP), biomarkers, echocardiography, and cardiac magnetic resonance imaging (subset). HFpEF [left ventricular ejection fraction (LVEF) ≥ 50%] was compared with HF with mildly reduced LVEF (HFmrEF; LVEF 41-49%) and with HF with reduced LVEF (HFrEF; LVEF ≤ 40%). We included 547 patients whereof HFpEF (n = 137; 25%), HFmrEF (n = 61; 11%), and HFrEF (n = 349; 64%). HFpEF patients were older (76; 70-81 years; median; interquartile range) than HFrEF (67; 58-74; P < 0.001), more often women (49% vs. 30%; P < 0.001), and had significantly higher comorbidity burden. They more often had atrial fibrillation, hypertension, and renal dysfunction. NT-proBNP was lower in HFpEF (896; 462-1645 ng/L) than in HFrEF (1160; 563-2370; P = 0.005). In HFpEF, left ventricular (LV) diameters and volumes were smaller (P < 0.001) and septal and posterior wall thickness and relative wall thickness higher (P < 0.001). E/é ≥ 14 was present in 26% of HFpEF vs. 32% of HFrEF (P = 0.017) and left atrial volume index > 34 mL/m2 in 57% vs. 61% (P = 0.040). HFmrEF patients were intermediary between HFpEF and HFrEF for LV mass, LV volumes, and RV volumes but had the highest proportion of left ventricular hypertrophy and the lowest proportion of elevated E/é. CONCLUSIONS: Phenotype data in new onset HF patients recruited in a broad clinical setting showed that 25% had HFpEF, were older, more often women, and had greater comorbidity burden. PREFERS is well suited to further explore biomarker and imaging components of HFpEF pathophysiology and may contribute to the emerging knowledge of HF epidemiology. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03671122.