Myocardial Fibrosis Predicts Ventricular Arrhythmias and Sudden Death After Cardiac Electronic Device Implantation.

BACKGROUND: Increasing evidence supports a link between myocardial fibrosis (MF) and ventricular arrhythmias. OBJECTIVES: The purpose of this study was to determine whether presence of myocardial fibrosis on visual assessment (MFVA) and gray zone fibrosis (GZF) mass predicts sudden cardiac death (SCD) and ventricular fibrillation/sustained ventricular tachycardia after cardiac implantable electronic device (CIED) implantation. METHODS: In this prospective study, total fibrosis and GZF mass, quantified using cardiovascular magnetic resonance, was assessed in relation to the primary endpoint of SCD and the secondary, arrhythmic endpoint of SCD or ventricular arrhythmias after CIED implantation. RESULTS: Among 700 patients (age 68.0 ± 12.0 years), 27 (3.85%) experienced a SCD and 121 (17.3%) met the arrhythmic endpoint over median 6.93 years (IQR: 5.82-9.32 years). MFVA predicted SCD (HR: 26.3; 95% CI: 3.7-3,337; negative predictive value: 100%). In competing risk analyses, MFVA also predicted the arrhythmic endpoint (subdistribution HR: 19.9; 95% CI: 6.4-61.9; negative predictive value: 98.6%). Compared with no MFVA, a GZF mass measured with the 5SD method (GZF5SD) >17 g was associated with highest risk of SCD (HR: 44.6; 95% CI: 6.12-5,685) and the arrhythmic endpoint (subdistribution HR: 30.3; 95% CI: 9.6-95.8). Adding GZF5SD mass to MFVA led to reclassification of 39% for SCD and 50.2% for the arrhythmic endpoint. In contrast, LVEF did not predict either endpoint. CONCLUSIONS: In CIED recipients, MFVA excluded patients at risk of SCD and virtually excluded ventricular arrhythmias. Quantified GZF5SD mass added predictive value in relation to SCD and the arrhythmic endpoint.

Natural History of Functional Tricuspid Regurgitation Quantified by Cardiovascular Magnetic Resonance.

BACKGROUND: Quantitation of tricuspid regurgitant (TR) severity can be challenging with conventional echocardiographic imaging and may be better evaluated using cardiovascular magnetic resonance (CMR). OBJECTIVES: In patients with functional TR, this study sought to examine the relationship between TR volume (TRVol) and TR fraction (TRF) with all-cause mortality. METHODS: We examined 547 patients with functional TR using CMR to quantify TRVol and TRF. The primary outcome was all-cause mortality. Thresholds for mild, moderate, and severe TR were derived based on natural history outcome data. RESULTS: During a median follow-up of 2.6 years (interquartile range: 1.7 to 3.3 years), there were 93 deaths, with an estimated 5-year survival of 79% (95% confidence interval [CI]: 73% to 83%). After adjustment of clinical and imaging variables, including RV function, both TRF (adjusted hazard ratio [AHR] per 10% increment: 1.26; 95% CI: 1.10 to 1.45; p = 0.001) and TRVol (AHR per 10-ml increment: 1.15; 95% CI: 1.04 to 1.26; p = 0.004) were associated with mortality. Patients in the highest-risk strata of TRVol ≥45 ml or TRF ≥50% had the worst prognosis (AHR: 2.26; 95% CI: 1.36 to 3.76; p = 0.002 for TRVol and AHR: 2.60; 95% CI: 1.45 to 4.66; p = 0.001 for TRF). CONCLUSIONS: This is the first study to use CMR to assess independent prognostic implications of functional TR. Both TRF and TRVol were associated with increased mortality after adjustment for clinical and imaging covariates, including right ventricular ejection fraction. A TRVol of ≥45 ml or TRF of ≥50% identified patients in the highest-risk strata for mortality. These CMR thresholds should be used for patient selection in future trials to determine if tricuspid valve intervention improves outcomes in this high-risk group.

Emerging Techniques for Risk Stratification in Nonischemic Dilated Cardiomyopathy: JACC Review Topic of the Week.

Dilated cardiomyopathy (DCM) is a common condition, which carries significant mortality from sudden cardiac death and pump failure. Left ventricular ejection fraction has conventionally been used as a risk marker for sudden cardiac death, but has performed poorly in trials. There have been significant advances in the areas of cardiac magnetic resonance imaging and genetics, which are able to provide useful rick prediction in DCM. Biomarkers and cardiopulmonary exercise testing are well validated in the prediction of risk in heart failure; however, they have been tested less specifically in the DCM setting. This review will discuss these methods with a view toward multiparametric risk assessment in DCM with the hope of creating parametric risk models to predict sudden cardiac death and pump failure in the DCM population.

Long-term changes of right ventricular myocardial deformation and remodeling studied by cardiac magnetic resonance imaging in patients with chronic thromboembolic pulmonary hypertension following pulmonary thromboendarterectomy.

BACKGROUND: Right ventricular (RV) afterload in patients with chronic thromboembolic pulmonary hypertension (CTEPH) is associated with reduced myocardial contractility and ventriculoarterial coupling. The impact of increased afterload on RV myocardial deformation was assessed by comparing the characteristics of CTEPH patients to healthy controls at baseline, and by comparing characteristics of CTEPH patients before and 12 months after pulmonary endarterectomy (PEA). METHODS: Cardiac deformation and function of CTEPH patients (n = 20) and healthy controls (n = 20) were assessed by cardiac magnetic resonance (CMR). CTEPH patients were also examined with right heart catheterization before and 12 months after PEA. RESULTS: PEA resulted in significant improvement of invasive hemodynamics and normalization of RV hypertrophy and right atrial, RV and left ventricular dimensions and volumes. RV ejection fraction improved from 30 ±â€¯13% at baseline to 44 ±â€¯10% at 12 months (p < 0.0001) but remained decreased compared with control subjects (54 ±â€¯4%, p < 0.05). RV global circumferential strain (GCS) normalized 12 months after PEA, but RV global longitudinal strain (GLS) remained significantly lower in CTEPH patients than controls (baseline -12.9 ±â€¯3.3% vs. -16.5 ±â€¯3.6% at 12 months p < 0.01, vs. controls -19.3 ±â€¯3.2%, p < 0.05). RV mass changes were significantly correlated with RV-ejection fraction, RV-GLS, and RV-GCS. RV-pulmonary arterial coupling with the volume method improved at 12 months (0.49 ±â€¯0.30 vs. 0.84 ±â€¯0.31, p < 0.0005), but remained significantly reduced compared with healthy controls (1.19 ±â€¯0.20, p < 0.0005). CONCLUSION: RV global longitudinal and circumferential myocardial three-dimensional strain by CMR improved significantly in CTEPH patients 12 months after PEA. Improvements in myocardial deformation were associated with regression of RV hypertrophy and decrease in pulmonary artery pressure.

Long term cardiovascular magnetic resonance phenotyping of anthracycline cardiomyopathy.

BACKGROUND: Anthracycline cardiomyopathy contributes to the morbidity and mortality of cancer survivors but long-term data are lacking. This study sought to describe the phenotype of long-term anthracycline cardiomyopathy, the prevalence of myocardial fibrosis and its association with cardiac remodeling, systolic function and clinical outcomes. METHODS AND RESULTS: We undertook contrast-enhanced CMR in 81 cancer survivors at median 5 years after anthracycline (mean dose 279 SD 89 mg/m2). Participants were aged 55 SD 14 years; 68% were female. Mean LVEF was impaired (49 SD 12%), driven by a pathological increase in iLVESV (47 SD 23 ml/m2). 19% of participants exhibited LGE, which was associated with significant adverse left ventricular remodeling and reduced systolic function (iLVEDV: 102 SD 34 vs 83 SD 21 ml/m2, p = 0.03; iLVESV 61 SD 32 vs 43 SD 20 ml/m2, p = 0.03; LVEF: 43 SD 11 vs 50 SD 12%, p = 0.03). In subgroup analysis of 36 patients, 36% had elevated native T1 measurements, which was associated with significant adverse left ventricular remodeling (iLVEDV: 97 SD 22 vs 74 SD 19 ml/m2, p = 0.002; iLVESV: 56 SD 22 vs 35 SD 15 ml/m2, p = 0.005), reduced systolic function (LVEF 44 SD 13 vs 55 SD 9%, p = 0.01), and hospitalizations for heart failure (38% vs 9%, p = 0.03). Absolute native T1 measurements correlated significantly with iLVEDV (p ≤ 0.001, R2 0.33), iLVESV (p < 0.001, R2 0.36), LVEF (p < 0.001, R2 0.35), LAVi (p = 0.04, R2 0.12) and MAPSE (p = 0.02, R2 0.14). CONCLUSIONS: Long-term anthracycline cardiomyopathy is characterized by pathologically increased iLVESV. Both LGE and elevated native T1 measurements were associated with significant adverse cardiac remodeling and reduced systolic function, and the latter with heart failure hospitalizations.

Clinical impact of cardiovascular magnetic resonance with optimized myocardial scar detection in patients with cardiac implantable devices.

BACKGROUND: Myocardial scar assessment using late gadolinium enhancement Cardiovascular Magnetic Resonance (LGE CMR) is commonly indicated for patients with cardiac implantable electronic devices (CIEDs), however metal artifact can degrade images. We evaluated the clinical impact of LGE CMR incorporating a device-dependent metal artifact reduction strategy in patients with CIEDs. METHODS: 136 CMR studies were performed in 133 consecutive patients (age 56 ±â€¯19 years, 69% male) with CIEDs (22% implantable loop recorders [ILRs], 40% permanent pacemakers [PPMs], 38% implantable cardioverter defibrillators [ICDs]; 42% non-MRI conditional) over 2 years, without complication. LGE imaging was tailored to the CIED, using a wideband sequence for left-sided PPMs and ICDs and conventional sequences for ILRs and right-sided PPMs, scoring segmental artifact. Diagnostic utility and impact on clinical management were scored by consensus of experts. RESULTS: CMR provided unexpected diagnoses in 22 (16%) and changed management in 113 (83%) patients. Myocardial scar was present in 92 (68%), with other abnormalities detected in another 13%. Using conventional LGE, 43 (32%) studies were non-diagnostic (79% of defibrillators) compared to 0% using wideband LGE imaging. Wideband LGE results changed clinical management in an additional 39 (75%) defibrillator patients and 10 (19%) pacemaker patients when compared to imaging with conventional LGE sequences. CONCLUSION: The clinical yield from CMR using optimized LGE sequences in patients with CIEDs is high with no demonstrated clinical risk. A device-dependent LGE imaging strategy using wideband LGE is needed to achieve clinical utility especially in ICD recipients.

Aortic angle is associated with neo-aortic root dilatation and regurgitation following arterial switch operation.

INTRODUCTION: Neo-aortic root dilatation and regurgitation are common progressive long-term complications of the arterial switch operation (ASO) for transposition of the great arteries (TGA) with increasing clinical burden. While several risk factors have been identified, most are constitutional. The acute aortic angle commonly seen after ASO might alter aortic dynamics and facilitate progression of the neo-aortic root dilatation and aortic regurgitation, but insufficient data is available. We intend to assess the effect of the aortic angle in the extent of neo-aortic root dilatation and presence of regurgitation. METHODS: Retrospective analysis of TGA patients undergoing CMR after ASO at a single tertiary centre from November 2010 to July 2017. RESULTS: 180 patients were analysed, 157 of which having adequate imaging of the aortic arch and root. Neo-aortic root Z score was normally distributed with 73% of patients having a Z score > 2. The aortic angle had a significant (p < 0,001) inverse relationship with the neo-aortic root Z score both in univariate and multivariate linear regression. Other significant associations were male gender and the concomitant presence of a VSD or a dysplastic neo-aortic valve. The presence of neo-aortic regurgitation was also inversely correlated with the aortic angle. The presence of a bicuspid neo-aortic valve was another significant association, further correlating with the more severe forms. CONCLUSIONS: Acute aortic angles associate more extensive neo-aortic root dilatation and higher incidence of regurgitation. We believe a surgical technique promoting less acute aortic angles has potential for ameliorating the long-term outcomes of TGA.

Long term prognostic importance of late gadolinium enhancement in first-presentation non-ischaemic dilated cardiomyopathy.

BACKGROUND: Presence of myocardial fibrosis in well-established non-ischaemic dilated cardiomyopathy (NIDCM) is associated with adverse clinical outcomes. However, the impact of myocardial fibrosis at first presentation in NIDCM, and its long-term association with left ventricular (LV) dysfunction, heart failure (HF) and ventricular arrhythmia (VA) remains unclear. We investigated whether the presence of myocardial fibrosis quantified by late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) at presentation, is independently associated with long-term major adverse cardiovascular events (MACE) in patients with first presentation NIDCM. METHODS: Consecutive patients with a first diagnosis of NIDCM were recruited. Patients underwent LGE-CMR at baseline. Replacement myocardial fibrosis by LGE-CMR was quantified by experienced observers blinded to patient outcome. MACE was defined as a composite end-point including cardiac death, HF rehospitalisation and the occurrence of sustained VA. RESULTS: Fifty-one patients with first presentation NIDCM were included, of which 49 (96%) had follow up and outcome data. Median follow up was 8.2 years. Both the LGE positive and LGE negative groups had similar clinical characteristics at follow up. In univariate Cox regression analysis, positive LGE was associated with MACE (HR:3.44; 95% CI:1.89 to 6.24, p-value < 0.001) and HF rehospitalisation (HR:2.89; 95% CI:1.42 to 5.85, p-value = 0.003). In multivariate Cox regression, positive LGE-CMR was independently associated with MACE (HR:3.53; 95% CI:1.51 to 8.27, p-value = 0.004) and HF rehospitalisation (HR:3.07; 95% CI:1.24 to 7.59, p-value = 0.015). CONCLUSIONS: The presence of myocardial fibrosis in first presentation NIDCM is independently associated with an increased risk of HF rehospitalisation, at long term follow-up.

Echocardiographic Screening for Pulmonary Hypertension in Congenital Heart Disease: JACC Review Topic of the Week.

Echocardiography is the mainstay in screening for pulmonary hypertension (PH). International guidelines suggest echocardiographic parameters for suspecting PH, but these may not apply to many adults with congenital heart disease (ACHD). PH is relatively common in ACHD patients and can significantly affect their exercise capacity, quality of life, and prognosis. Identification of patients who have developed PH and who may benefit from further investigations (including cardiac catheterization) and treatment is thus extremely important. A systematic review and survey of experts from the United Kingdom and Ireland were performed to assess current knowledge and practice on echocardiographic screening for PH in ACHD. This paper presents the findings of the review and expert statements on the optimal approaches when using echocardiography to assess ACHD patients for PH, with particular focus on major subgroups: patients with right ventricular outflow tract obstruction, patients with systemic right ventricles, patients with unrepaired univentricular circulation, and patients with tetralogy of Fallot with pulmonary atresia.

Left Ventricular Scar and Prognosis in Chronic Chagas Cardiomyopathy.

BACKGROUND: Patients with chronic Chagas cardiomyopathy (CCC) have pronounced myocardial fibrosis, which may predispose to sudden cardiac death, despite well-preserved global left ventricular (LV) systolic function. Cardiac magnetic resonance can assess myocardial fibrosis by late gadolinium enhancement (LGE) sequences. OBJECTIVES: This prospective study evaluated if the presence of scar by LGE predicted hard adverse outcomes in a cohort of patients with CCC. METHODS: A prospective cohort of 140 patients with CCC (52.1% female; median age 57 years [interquartile range: 45 to 67 years]) were included. Cardiac magnetic resonance cine and LGE imaging were performed at enrollment with a 1.5-T scanner. The primary endpoint was the combination of cardiovascular death and sustained ventricular tachycardia. The secondary endpoint was the combination of cardiovascular death, sustained ventricular tachycardia, or cardiovascular hospitalization during follow-up. RESULTS: After a median of 34 months (interquartile range: 24 to 49 months) of follow-up, 11 cardiovascular deaths, 3 episodes of sustained ventricular tachycardia, and 20 cardiovascular hospitalizations were recorded. LGE scar was present in 71.4% of the patients, with the lateral, inferolateral, and inferior walls most commonly affected. Patients with positive LGE had lower LV ejection fraction and higher LV end-diastolic volume and LV mass than patients without LGE. No difference in other cardiovascular risk factors was noted. Patients with scar had higher event rates compared with those without scar for the primary (p = 0.043) and the secondary (p = 0.016) endpoint. In multivariable analysis, age and LGE area were related to primary outcome; age and lower LV ejection fraction were related to the secondary outcome. The pattern of LGE myocardial fibrosis was transmural, focal, or diffuse scar in approximately one-third of patients with positive LGE, and no pattern was specifically related to outcomes. CONCLUSIONS: In patients with CCC, presence of scar by LGE is common and is strongly associated with major adverse outcomes.

Long-Term Prognostic Value of Myocardial Fibrosis in Patients With Chagas Cardiomyopathy.

BACKGROUND: Myocardial fibrosis (MF) according to cardiac magnetic resonance (CMR) is a frequent finding in Chagas cardiomyopathy and has been associated with risk factors of poor outcome. OBJECTIVES: The goal of this study was to determine the prognostic value of MF in predicting combined hard events or all-cause mortality. METHODS: Patients with Chagas cardiomyopathy who had a previous CMR evaluation were included, and clinical follow-up was retrospectively obtained. The primary outcome was a combination of all-cause mortality, heart transplantation, antitachycardia pacing or appropriate shock from an implantable cardioverter-defibrillator, and aborted sudden cardiac death; the secondary outcome was all-cause mortality. RESULTS: A total of 130 patients were included; mean age was 53.6 ± 11.5 years, and 53.9% were female. The majority of patients reported no symptoms of heart failure or arrhythmia, but electrocardiographic and echocardiographic abnormalities were common. On CMR, left ventricular dilatation and dysfunction were frequent, and MF was found in 76.1%, with a mean mass of 15.2 ± 16.5 g. Over a median follow-up of 5.05 years, 58 (44.6%) patients reached the combined endpoint, and 45 (34.6%) patients died. MF was associated with the primary outcome as a continuous variable (adjusted hazard ratio: 1.031; 95% CI: 1.013 to 1.049; p = 0.001) and as a categorical variable (MF ≥12.3 g) (adjusted hazard ratio: 2.107; 95% CI: 1.111 to 3.994; p = 0.022), independently from the Rassi risk score. MF expressed as a continuous variable was also associated with all-cause mortality (adjusted hazard ratio: 1.028; 95% CI: 1.005 to 1.051; p = 0.017) independently from the Rassi risk score. CONCLUSIONS: MF is an independent predictor of adverse outcome in Chagas cardiomyopathy. Our data may support the use of CMR in better risk-stratifying this population and possibly guiding therapy.

Microvascular obstruction in non-infarct related coronary arteries is an independent predictor of major adverse cardiovascular events in patients with ST segment-elevation myocardial infarction.

BACKGROUND: Coronary microvascular obstruction (MVO) in infarct-related artery (IRA) territory has been associated with worse cardiovascular outcomes in patients presenting with ST-segment elevation myocardial infarction. However, the prognostic value of non-IRA MVO in this patient population remains unknown. METHODS AND RESULTS: One hundred ninety nine patients presenting to our institution with STEMI were enrolled. All patients underwent primary percutaneous coronary intervention per institutional STEMI protocol followed by a cardiac MRI within 1 week of presentation and the IRA and non-IRA MVO segments were determined. All cause death, recurrent myocardial infarction, hospitalization for heart failure, and ventricular tachycardia were counted as major adverse cardiovascular events (MACE). Patients with non-IRA MVO had lower composite MACE free survival at 6 months (HR 2.15, 95% CI, 1.06-4.35; p = 0.029) compared to those without non-IRA MVO. In a sub-analysis of patients with multi vessel disease (MVD), patients with non-IRA MVO also had lower composite MACE-free survival at 6 months as compared to those without non-IRA MVO (HR 2.47, 95% CI, 1.02-5.97; p = 0.037). Non-IRA MVO continued to be predictive of MACE in a cox proportional hazards model adjusting for additional prognostic factors using inverse probability weighting (p = 0.007). Non-IRA MVO was more prevalent in patients with LAD culprit vessel STEMI rather than those with RCA or Circumflex culprit vessels (p < 0.001). CONCLUSIONS: Patients presenting with STEMI and non-IRA MVO have significantly lower MACE free survival at 6 months as compared to those without non-IRA MVO.

Admission heart rate and in-hospital course of patients with Takotsubo syndrome.

BACKGROUND: In-hospital course of patients with Takotsubo syndrome (TS) is quite heterogeneous and life-threatening complications are not uncommon in the acute phase. The role of heart rate (HR) as a predictor of prognosis has not been sufficiently investigated in this setting. The study aims to assess the impact of HR at presentation on in-hospital course of patients with TS. METHODS: The study population included 221 patients with TS enrolled in a multicentric registry. HR at admission was evaluated on the first electrocardiogram. According to tertile distribution of HR at presentation, 3 groups were identified: Group A (HR ≤ 76 beats per minute (bpm), n = 76), Group B (HR 77-95 bpm, n = 74) and Group C (HR > 95 bpm, n = 71). Acute in-hospital complications were defined as occurrence of severe pump failure and major arrhythmias. RESULTS: 32 (14.4%) patients experienced complicated in-hospital course. HR on admission was significantly higher (108 bpm vs. 85 bpm; p < 0.001) and ejection fraction (EF) lower (35% vs. 40%; p = 0.009) in patients with complications than in those without. Patients in Group C experienced a 5-fold higher rate of complications compared to group A and B. After multivariate analysis, higher HR (odds ratio 1.34 per 10 bpm increase, 95% confidence interval (CI) 1.12-1.59; p = 0.001) and lower EF (odds ratio 1.24 per 5% decrease, 95% CI 1.01-1.54; p = 0.049) remained independently associated with a worse outcome. CONCLUSION: In a large population with TS, high HR on admission independently predicted complicated in-hospital course.

Role of T2 mapping in left ventricular reverse remodeling after TAVR.

BACKGROUND: Patients with severe aortic stenosis (AS) are subjected to left ventricular hypertrophy (LVH) with increasing morbidity and mortality. Transcatheter aortic valve replacement (TAVR) induces reverse left ventricular remodeling which can be monitored by cardiovascular magnetic resonance (CMR). CMR is able to analyze myocardial tissue properties by magnetic relaxation times (parametric CMR). The objective of this study was to study myocardial T2 relaxation in reverse ventricular remodeling after TAVR. METHODS: Forty-three patients with severe AS (19 males, 81.9 ±â€¯4.9 years) underwent CMR with T2 mapping before and 6 months after TAVR. A cohort of age- and gender-matched volunteers served as controls. Analyzed parameters included left ventricular ejection fraction (LV-EF), mass indexed to body surface area (LVMi), interventricular septum thickness (IVS), end-diastolic volume (LVEDV), global longitudinal strain (GLS), peak diastolic strain rate (SRe) and myocardial T2 values. RESULTS: CMR characteristics for patients with AS displayed LVH concomitant to elevated myocardial T2 values, reduced GLS and SRe. Patients with T2 values above 70.2 ms at baseline were characterized by eccentric hypertrophy with reduced LV-EF. T2 values decreased after TAVR (67.4 ±â€¯3.4 to 63.3 ±â€¯4.2 ms, p < 0.01) during left ventricular remodeling. Patients with T2 values above 70.2 ms at baseline exhibited pronounced reverse remodeling which proved to be a significant predictor of LV-EF improvement and LVEDV reduction in uni- and multivariate analyses. CONCLUSIONS: Multiparametric CMR can be used to characterize myocardial hypertrophy due to severe AS and to monitor myocardial adaptations after TAVR. It may provide additional information in the prediction of left ventricular remodeling after TAVR.

Prognostic value of myocardial deformation imaging by cardiac magnetic resonance feature-tracking in patients with a first ST-segment elevation myocardial infarction.

AIM: Scarce data are available whether cardiac magnetic resonance (CMR) assessment of myocardial deformation provides independent and incremental prognostic information in patients with ST-segment elevation myocardial infarction (STEMI). The aim of the present study was to investigate the prognostic utility of CMR feature-tracking derived left ventricular (LV) global circumferential strain (GCS) in STEMI patients. METHODS: A total of 180 patients (mean age 60 ±â€¯12 years, 72% male) admitted because of a first STEMI were included. CMR with late gadolinium enhancement (LGE) imaging was performed to assess LV function, infarct size, and microvascular obstruction. The feature-tracking analysis was applied to cine-CMR short-axis images to assess LV GCS. Patients were followed-up for a median of 95 months. The outcome event was a composite endpoint including cardiovascular death, aborted sudden cardiac death, and hospitalization for heart failure. RESULTS: During follow-up, 40 (22%) patients experienced at least 1 event. After adjustment for other clinical and CMR imaging characteristics, LV GCS remained significantly and independently associated with the outcome event (HR 1.16 per %; 95% CI 1.07-1.25; p < 0.001). A significant increase of global χ2 was observed when adding LV GCS to a model including clinical and non-contrast CMR variables (χ2 change = 8.2; p = 0.004) and to a model including clinical, non-contrast and LGE variables (χ2 change = 4.8; p = 0.028). CONCLUSION: LV GCS assessed by CMR feature-tracking can predict a worse long-term prognosis in patients admitted with a first STEMI. More importantly, the predictive ability of LV GCS is incremental to other clinical and CMR variables.

Quantitative and qualitative assessment of acute myocardial injury by CMR at multiple time points after acute myocardial infarction.

BACKGROUND: Recent experimental studies have shown a dynamic time course of myocardial edema with an initial wave of edematous reaction within hours after reperfusion which almost resolved at 24 h. However, this dynamic pattern appears to be absent in clinical cohort studies. Thus far, no studies have combined a quantitative and qualitative assessment of acute myocardial injury in a large clinical cohort to explain these divergent findings. METHODS: A cohort of 225 patients (59 ±â€¯11 years, 83% men) with successfully reperfused STEMI within 12 h of symptom onset were included. Quantitative measurements of myocardial damage such as T1 mapping and T2 triple short-tau inversion recovery (STIR), contrast-to-noise ratio (CNR) and their impact on area-at-risk (AAR), infarct size (IS), and myocardial salvage index (MSI) were assessed at different time points. One-way analysis of variance (ANOVA) and linear regression analysis was used to compare myocardial damage at the different time points. RESULTS: A small fraction of patients underwent CMR within 24 h of reperfusion (17/225, 7.6%). No significant variations in AAR, IS, MSI, T2 STIR CNR, or native T1 maps were observed between the different time points after reperfusion. Time of CMR was not a significant predictor of AAR (P = 0.90), IS (P = 0.27), MSI (P = 0.23) or T2 STIR CNR (P = 0.23). CONCLUSIONS: The majority of CMR exams in STEMI patients are performed outside the dynamic time window of early post-MI edema. The stable pattern of markers of acute myocardial damage at different time points suggests these markers are reliable for the prognostication of patients after STEMI.

Percutaneous pulmonary valve implantation in patients with dysfunction of a "native" right ventricular outflow tract - Mid-term results.

BACKGROUND: To investigate the feasibility and mid-term results of percutaneous pulmonary valve implantation (PPVI) in patients with conduit free or "native" right ventricular outflow tracts (RVOT). METHODS AND RESULTS: We identified all 18 patients with conduit free or "native" right ventricular outflow tract, who were treated with percutaneous pulmonary valve implantation (PPVI) in our institution. They were divided into two groups - these in whom the central pulmonary artery was used as an anchoring point for the preparation of the landing zone (n=10) for PPVI and these, in whom a pulmonary artery branch was used for this purpose (n=8). PPVI was performed successfully in all patients with significant immediate RVOT gradient and pulmonary regurgitation grade reduction. Four patients had insignificant paravalvular regurgitation. In one patient the valve was explanted after 4months because of bacterial endocarditis. A follow-up of 19 (4-60) months showed sustained good function of the other implanted valves. The MRI indexed right ventricular end diastolic volume significantly decreased from 108(54-174) ml/m2 before the procedure to 76(60-126) ml/m2 six months after PPVI, p=0.01. CONCLUSIONS: PPVI is feasible with good mid-term results in selected patients with a "native" RVOT without a previously implanted conduit. Creating a stable landing zone with a diameter less than the largest available valve (currently 29mm) is crucial for the technical success of the procedure. Further studies and the development of new devices could widen the indications for this novel treatment.