Usefulness of right ventriculography compared with computed tomography for ruling out the possibility of lead perforation before lead extraction.

PURPOSE: High-risk patients can be identified by preprocedural computed tomography (CT) before lead extraction. However, CT evaluation may be difficult especially for lead tip identification due to artifacts in the leads. Selective right ventriculography (RVG) may enable preprocedural evaluation of lead perforation. We investigated the efficacy of RVG for identifying right ventricular (RV) lead perforation compared with CT in patients who underwent lead extraction. METHODS: Ninety-five consecutive patients who were examined by thin-section non-ECG-gated multidetector CT and RVG before lead extraction were investigated retrospectively. Newly recognized pericardial effusion after lead extraction was used as a reference standard for lead perforation. We analyzed the prevalence of RV lead perforation diagnosed by each method. The difference in the detection rates of lead perforation by RVG and CT was evaluated. RESULTS: Of the 115 RV leads in the 95 patients, lead perforation was diagnosed for 35 leads using CT, but the leads for 29 (83%) of those 35 leads diagnosed as lead perforation by CT were shown to be within the right ventricle by RVG. Three patients with 5 leads could not be evaluated by CT due to motion artifacts. The diagnostic accuracies of RVG and CT were significantly different (p < 0.001). There was no complication of pericardial effusion caused by RV lead extraction. CONCLUSION: RVG for identification of RV lead perforation leads to fewer false-positives compared to non-ECG-gated CT. However, even in cases in which lead perforation is diagnosed, most leads may be safely extracted by transvenous lead extraction.

Ventricular arrhythmias in Takotsubo Syndrome: incidence, predictors and clinical outcomes.

AIMS: To investigate predictors of the occurrence of subacute ventricular arrhythmias (VAs), defined as any VAs presenting after 48 h from admission in patients with Takotsubo Syndrome (TTS), and to evaluate the related in-hospital mortality. METHODS: This is a retrospective single-center study enrolling patients admitted between 2012 and 2017 with TTS according to International Takotsubo diagnostic criteria. Data collection included ECG on admission and at 48 h, telemetry monitoring and transthoracic echocardiogram. RESULTS: We enrolled 93 patients; during in-hospital stay (mean 14 ±â€Š16 days) subacute VAs occurred in 25% of patients (VAs group). Life-threatening VAs occurred in 6% of patients (3 sustained ventricular tachycardia, 1 torsade de pointes, 1 ventricular fibrillation) and not life-threatening VAs in 19% (6 non-sustained ventricular tachycardia and 12 premature ventricular contractions > 2000 in 24 h). Mortality was higher in the VAs than in the non-VAs group (P = 0.03), without differences in terms of life-threatening and not life-threatening subacute VAs (P = 0.65) and VAs on admission (P = 0.25). Logistic regression identified the following independent predictors of subacute VAs occurrence: VAs on admission {odds ratio [OR] 22.5 (3.9-131.8), P = 0.001]}, New York Heart Association (NYHA) class III-IV on admission [OR 6.7 (1.3- 34.0), P = 0.021] and QTc at 48 h [OR 1.01 (1.00-1.03), P = 0.046]. CONCLUSION: TTS patients with VAs and NYHA class III-IV on admission and higher QTc at 48 h are at increased risk of subacute VAs occurrence, associated with higher in-hospital mortality. Awareness of this potential complication is critical for proper patients management.

Alto rendimiento de la Cardiología Nuclear hoy en el diagnóstico cardiológico / High performance of Nuclear Cardiology today in cardiac diagnosis

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Value of circulating miRNA-21 in the diagnosis of subclinical diabetic cardiomyopathy.

BACKGROUND: Diabetic cardiomyopathy (DCM) is a type of cardiac dysfunction that affects approximately 12% of diabetic patients, ultimately leading to heart failure or even death. However, there is currently no efficient or specific biomarker for DCM diagnosis. METHODS: A total of 266 subjects with type II diabetes (T2DM) were enrolled in this study and were divided into the T2DM with cardiac dysfunction (DCM) group and T2DM without cardiac dysfunction (non-DCM) group. The diagnostic efficacy of miR-21 was determined and compared with that of serum hemoglobin A1c% (HbA1c%). Db/db mice and H9c2 cells stimulated with high glucose (HG)/high fatty acid (PA) were used as in vivo and in vitro models of DCM, respectively. RESULTS: Through echocardiography and gated-myocardial perfusion imaging (gated-MPI), 49 patients were selected to be enrolled in the DCM group, with 49 matched controls in the non-DCM group. The circulating miR-21 levels were significantly decreased in the DCM group compared to the non-DCM group (P < 0.001). The diagnostic efficiency of miR-21 (area under the curve AUC = 0.899) was higher than that of other parameters, including HbA1c%. Moreover, when miR-21 was combined with the duration of diabetes, HbA1c%, and lipid profiles, the AUC was the highest (AUC = 0.939) and had the highest diagnostic efficiency. Furthermore, overexpression of miR-21 improved the impaired mitochondrial biogenesis and decreased the cardiomyocyte apoptosis induced by HG/PA, while inhibition of miR-21 exerted the opposite effects. CONCLUSIONS: Our findings identify circulating miR-21 as a novel biomarker in the diagnosis of DCM and provide an underlying mechanism for miRNA-based therapy for the treatment of DCM. TRIAL REGISTRATION: The study was approved by the Ethics Committee of the Third Affiliated Hospital of Soochow University and has been registered in the Chinese Clinical Trial Registry (ChiCTR1900027080).

Cicatriz miocárdica arritmogénica localizada mediante el uso combinado de la SPECT con 123I-MIBG y la RMN cardíaca / Arrhythmogenic myocardial scar localized through the combined use of 123I-MIBG SPECT and cardiac MRI

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Left Ventricular Noncompaction: A Rare Cause of Effort Angina Unveiled During Left Heart Catheterization.

Effort angina is an under-appreciated presentation of left ventricular non-compaction that frequently leads to a late diagnosis. Cardiac ventriculography can assist in this diagnosis.

Transcatheter Closure of Perimembranous Ventricular Septal Defect with Aneurysm: Radiologic Characteristic and Interventional Strategy.

OBJECTIVES: We aimed to explore the radiologic characteristics and interventional strategies for perimembranous ventricular septal defect (pmVSD) with aneurysm. METHODS: 257 patients who underwent transcatheter closure of pmVSD with aneurysm were included in our study. We retrospectively reviewed the left ventricular opening of the aneurysm (a), diameter of the midsegment of the aneurysm (b), and diameter of the right ventricular opening of the aneurysm (c). If there were multiple defects within the aneurysm, the largest defect was denoted as c 1 and so forth. We developed a novel VSD classification method in which pmVSD with aneurysm was classified into three types (A, B, and C). When a >b ≥ c, it was classified as type A, when b > a ≥ c, it was type B, and when c > a ≥ b, it was type C; c/c 1 described the relationship among defects. RESULTS: All of the 257 cases of pmVSD with aneurysm were defined using left ventriculography: type A, 60, type B, 58, and type C, 139. Transcatheter closure was attempted in 244 patients and succeeded in 227 cases (success rate was 93.0%; 227/244). Forty symmetric VSD occluders and 13 asymmetric VSD occluders were used for type A aneurysm occlusion; 31 symmetric VSD occluders, 19 asymmetric VSD occluders, and one Amplatzer duct occluder II (ADOII) were used for type B; 59 VSD symmetric occluders, 59 asymmetric VSD occluders, three eccentric VSD occluders, and two ADOII were used for type C. Within 24 hours after procedure, 2.2% patients had postprocedural residual shunt, and 2.2% experienced malignant arrhythmia (including type II second-degree AVB, cAVB, and CLBBB). Two hundred and twelve patients completed follow-up (93%, 212/227). No new severe complications were reported during follow-up, except in one patient who underwent surgery (removal of the device, VSD repair, and tricuspid valvuloplasty) due to severe postprocedural tricuspid regurgitation. CONCLUSIONS: It is safe and effective to apply this method for the classification of pmVSD with aneurysm and its interventional strategy.

Cardiac MRI and radionuclide ventriculography for measurement of left ventricular ejection fraction in ICD candidates.

OBJECTIVE: Current guidelines provide left ventricular ejection fraction (LVEF) criterion for use of implantable cardioverter defibrillators (ICD) but do not specify which modality to use for measurement. We compared LVEF measurements by radionuclide ventriculography (RNV) vs cardiac MRI (CMR) in ICD candidates to assess impact on clinical decision making. METHODS: This single-centre study included 124 consecutive patients referred for assessment of ICD implantation who underwent RNV and CMR within 30 days for LVEF measurement. RNV and CMR were interpreted independently by experienced readers. RESULTS: Among 124 patients (age 64 ±â€¯11 years, 77% male), median interval between CMR and RNV was 1 day; mean LVEF was 32 ±â€¯12% by CMR and 33 ±â€¯11% by RNV (p = 0.60). LVEF by CMR and RNV showed good correlation, but Bland-Altman analysis showed relatively wide limits of agreement (-12.1 to 11.4). CMR LVEF reclassified 26 (21%) patients compared to RNV LVEF (kappa = 0.58). LVEF by both modalities showed good interobserver reproducibility (ICC 0.96 and 0.94, respectively) (limits of agreement -7.27 to 5.75 and -8.63 to 6.34, respectively). CONCLUSION: Although LVEF measurements by CMR and RNV show moderate agreement, there is frequent reclassification of patients for ICD placement based on LVEF between these modalities. Future studies should determine if a particular imaging modality for LVEF measurement may enhance ICD decision making and treatment benefit.

Myocardial strain imaging by cardiac magnetic resonance for detection of subclinical myocardial dysfunction in breast cancer patients receiving trastuzumab and chemotherapy.

BACKGROUND: Our objectives were to evaluate the temporal changes in CMR-based strain imaging, and examine their relationship with left ventricular ejection fraction (LVEF), in patients treated with trastuzumab. PATIENTS AND METHODS: In this prospective longitudinal observational study, 41 women with HER2+ breast cancer treated with chemotherapy underwent serial CMR (baseline, 6, 12, and 18 months) after initiation of trastuzumab (treatment duration 12 months). LVEF and LV strain (global longitudinal[GLS] and circumferential[GCS]) measurements were independently measured by 2 blinded readers. RESULTS: Of the 41 patients, 56% received anthracycline-based chemotherapy. Compared to baseline (60.4%, 95%CI 59.2-61.7%), there was a small but significant reduction in LVEF at 6 months (58.4%, 95%CI 56.7-60.0%, p = 0.034) and 12 months (57.9%, 95%CI 56.4-59.7%, p = 0.012), but not at 18 months (60.2%, 95%CI 58.2-62.2%, p = 0.93). Similarly, compared to baseline, GLS and GCS decreased significantly at 6 months (p = 0.024 and < 0.001, respectively) and 12 months (p = 0.002 and < 0.001, respectively) with an increase in LV end-diastolic volume, but not at 18 months. There were significant correlations between the temporal (6 month-baseline) changes in LVEF, and all global strain measurements (Pearson's r = -0.60 and r = -0.75 for GLS and GCS, respectively, all p < 0.001). CONCLUSION: There was a significant reduction in LV strain during trastuzumab treatment, which correlated with a concurrent subtle decline in LVEF and was associated with an increase in LV end-diastolic volume. LV strain assessment by CMR may be a promising method to monitor for subclinical myocardial dysfunction in breast cancer patients receiving chemotherapy. Future studies are needed to determine its prognostic and therapeutic implications.

Multi-modality imaging evaluation of recurrent Tako-tsubo syndrome in a patient with coronary artery fibromuscular dysplasia.

BACKGROUND: Integrated bedside and sophisticated cardiac imaging techniques help characterize the discrepancy between myocardial injury and mechanic dysfunction in acute myocardial infarction. CASE PRESENTATION: A 57 year-old woman presented with sudden onset chest pain and ventricular fibrillation after hearing of her brother's death. The electrocardiography indicated "anterior wall ST segment elevation myocardial infarction". Coronary angiography ruled out obstructive lesion in the major coronary arteries, but revealed fibromuscular dysplasia of the distal left anterior descending artery. The ventriculography showed remarkable ventricular dilation, which affected much broader myocardium than the culprit vessel supplied. In a subsequent cardiac magnetic resonance study, delayed contrast (gadolinium) image revealed a focal left ventricular (LV) apical infarction. Her LV systolic function normalized within 1 week, except for a residual apical hypokinesis. She developed recurrent chest pain and LV dilation when she was laid off 9 months later. After supportive therapy, her symptoms improved and LV dysfunction normalized again. CONCLUSIONS: "Tako-tsubo" syndrome can occur recurrently in the heart with pre-existing localized myocardial infarction. Its molecular mechanism and clinical significance warrants further investigation.

Puntualizaciones al documento de consenso en cardio-onco-hematología y a la revisión sobre técnicas de imagen cardiaca en detección de cardiotoxicidad / Remarks on the position paper on cardio-onco-hematology and remarks on the review of cardiac imaging modalities for the detection of cardiotoxicity

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Resultado del cierre incompleto de defecto tipo Gerbode con coil Nit-Occlud Lê VSD: hemolisis grave que precisa reintervención / Effect of incomplete closure of a Gerbode defect with the Nit-Occlud Lê VSD Coil: severe hemolysis requiring a second procedure

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Aplicabilidade da Cintilografia Miocárdica de Perfusão na Avaliação do Sincronismo Cardíaco / Applicability of Myocardial Perfusion Scintigraphy in the Evaluation of Cardiac Synchronization

Com o objetivo de avaliar de modo sistemático a literatura sobre a aplicabilidade da cintilografia de perfusão do miocárdio com análise de fase na investigação do dissincronismo cardíaco e na seleção de pacientes para terapia de ressincronização cardíaca (TRC), foi realizada uma revisão de artigos publicados através da base de dados PubMed nos últimos cinco anos. Os termos MeSH utilizados foram: heart failure, left ventricular, dyssynchrony, gatedspect, phase analysis e resynchronization therapy, sendo 99 artigos incluídos para discussão. O ecocardiograma com speckle-tracking continua sendo um método bastante utilizado na avaliação do dissincronismo, mas o advento da cintilografia de perfusão miocárdica com a técnica de análise de fase vem ganhando espaço, pois além de ser operador-independente, consegue avaliar no mesmo exame a viabilidade miocárdica. Seu uso se tornou mais difundido nos pacientes com bloqueio de ramo esquerdo e com indicação à TRC. A análise de fase também permite avaliar de forma altamente reprodutível o último segmento ventricular a se contrair, permitindo assim o melhor posicionamento do eletrodo da TRC. Sabendo-se que a presença, localização e extensão de fibrose no ventrículo esquerdo, associadas ao dissincronismo são determinantes da resposta à terapia de ressincronização, o gated-SPECT pode prover estas informações em um único exame e de modo reprodutível e acurado. O histograma de fase oferece diversos parâmetros que conferem maior sensibilidade e especificidade ao método. Parece que a técnica é capaz de agregar valor tanto na seleção quanto na avaliação de resposta de pacientes candidatos à TRC. Novos estudos estão sendo realizados para demonstrar a sua aplicabilidade clínica

The relationship between serum fibrosis markers and restrictive ventricular filling in patients with heart failure with reduced ejection fraction: A technetium-99m radionuclide ventriculography study.

Myocardial fibrosis leads to a restrictive diastolic filling pattern of the left ventricle which is associated with a poor prognosis in patients with heart failure. We investigated the relationship between cardiac fibrosis and restrictive filling pattern of the left ventricle measured by Tc99m left ventriculography in patients with chronic symptomatic heart failure. Serum cardiac extracellular matrix markers including type I and III aminoterminal propeptide of procollagen (PINP and PIIINP), matrix metalloproteinase-2,9 (MMP-2,9), and tissue inhibitor of MMP-1 (TIMP-1) were analyzed. Fifty-one (39 males) patients were enrolled. Their median age was 51.8 years, and median left ventricular ejection fraction was 31.9%. Time to peak filling rate of the left ventricle was significantly correlated with serum levels of the three cardiac extracellular matrix markers (TIMP-1, PIIINP, and MMP-2). The patients with a restrictive diastolic filling pattern of the left ventricle (time to peak filling rate ≤ 154 ms) had significantly higher levels of these extracellular matrix markers. In receiver operating characteristic curve analysis, areas under the curve of PIIINP, TIMP-1, and MMP-2 were 0.758, 0.695, and 0.751 to predict the presence of a restrictive pattern. In C-statistics, all three cardiac extracellular matrix markers significantly increased the area under the curve after adding creatinine. In net reclassification improvement and integrated discrimination improvement models, PIIINP and MMP-2 significantly improved the predictive power of age, creatinine and brain natriuretic peptide. In conclusion, serum extracellular matrix markers are significantly correlated with restrictive diastolic filling pattern of the left ventricle in patients with heart failure.

Cardiac monitoring in patients on trastuzumab: correlation of ultrasound and radionuclide ventriculography.

BACKGROUND: Guidance on cardiac surveillance during adjuvant trastuzumab therapy remains elusive. The recommended methods are two-dimensional echocardiography (2D-ECHO) and electrocardiography gated equilibrium radionuclide ventriculography (RNV). We assessed the correlation and possible specific merits of these two methods. METHODS: In a prospective cohort study in patients undergoing post-anthracycline adjuvant trastuzumab therapy, clinical assessment, 2D-ECHO and RNV were performed at baseline, 4, 8 and 12 months. The correlation between used methods was estimated with Pearson's correlation coefficient and Bland-Altman analysis. RESULTS: Ninety-two patients (mean age 53.6±9.0 years) were included. The correlation of LVEF measured by ECHO and RNV at each time point was statistically insignificant. Values obtained by ECHO were on average higher (3.7% to 4.5%). A decline in LVEF of ≥10% from baseline was noticed in 19 (24.4%) and 13 (14.9%) patients with ECHO and RNV, respectively, however in only one patient by both methods simultaneously. A decline in LVEF of ≥10% to below 50% was found in three and none patients according to RNV and ECHO measurements, respectively. CONCLUSIONS: There is a weak correlation of ECHO and RNV measurements in individual patient, the results obtained by the methods are not interchangeable. LVEF values determined by 2D-ECHO were on average higher compared to RNV determined ones. When in an asymptomatic patient a decline in LVEF requiring treatment interruption is detected by RNV ECHO re-evaluation and referral to a cardiologist is advised.