Sex-specific cardiac magnetic resonance pulmonary capillary wedge pressure.

Aims: Heart failure (HF) with preserved ejection fraction disproportionately affects women. There are no validated sex-specific tools for HF diagnosis despite widely reported differences in cardiac structure. This study investigates whether sex, as assigned at birth, influences cardiac magnetic resonance (CMR) assessment of left ventricular filling pressure (LVFP), a hallmark of HF agnostic to ejection fraction. Methods and results: A derivation cohort of patients with suspected pulmonary hypertension and HF from the Sheffield centre underwent invasive right heart catheterization and CMR within 24 h of each other. A sex-specific CMR model to estimate LVFP, measured as pulmonary capillary wedge pressure (PCWP), was developed using multivariable regression. A validation cohort of patients with confirmed HF from the Leeds centre was used to evaluate for the primary endpoints of HF hospitalization and major adverse cardiovascular events (MACEs). Comparison between generic and sex-specific CMR-derived PCWP was undertaken. A total of 835 (60% female) and 454 (36% female) patients were recruited into the derivation and validation cohorts respectively. A sex-specific model incorporating left atrial volume and left ventricular mass was created. The generic CMR PCWP showed significant differences between males and females (14.7 ± 4 vs. 13 ± 3.0 mmHg, P > 0.001), not present with the sex-specific CMR PCWP (14.1 ± 3 vs. 13.8 mmHg, P = 0.3). The sex-specific, but not the generic, CMR PCWP was associated with HF hospitalization (hazard ratio 3.9, P = 0.0002) and MACE (hazard ratio 2.5, P = 0.001) over a mean follow-up period of 2.4 ± 1.2 years. Conclusion: Accounting for sex improves precision and prognostic performance of CMR biomarkers for HF.

European Association of Cardiovascular Imaging (EACVI) survey on Cardiovascular Multimodality Imaging in Acute Myocarditis.

AIMS: To assess the current role of cardiac imaging in the diagnosis, management, and follow-up of patients with acute myocarditis (AM) through an European Association of Cardiovascular Imaging survey. METHODS AND RESULTS: A total of 412 volunteers from 74 countries responded to the survey. Most participants worked in tertiary centres(56%). All participants had access to echocardiography, while 79% and 75% had access to cardiac computed tomography (CCTA) and cardiac magnetic resonance (CMR), respectively. Less than half(47%) had access to myocardial biopsy and only 5% used this test routinely. CMR was performed within 7 days of presentation in 73% of cases. Non-ischemic late gadolinium enhancement (LGE,88%) and high-signal intensity in T2-weighted images(74%) were the most used diagnostic criteria for AM. CCTA was preferred to coronary angiography by 47% of participants to exclude coronary artery disease. Systematic prescription of beta-blockers and ACEi was reported by 38% and 32% of participants. Around a quarter of participants declared considering LGE burden as a reason to treat. Most participants (90%) reported performing a follow-up echocardiogram, while 63% scheduled a follow-up CMR. The main reason for treatment discontinuation was improvement of left ventricular ejection fraction(89%), followed by LGE regression(60%). In two-thirds of participants the decision to resume high-intensity sport was influenced by residual LGE. CONCLUSION: This survey confirms the high utilization of cardiac imaging in AM, but reveals major differences in how cardiac imaging is used and how the condition is managed between centres, underlining the need for recommendation statements in this topic.

European Association of Cardiovascular Imaging survey on the evaluation of mitral regurgitation.

AIMS: To evaluate the diagnosis and imaging of patients with mitral regurgitation (MR) and the management in routine clinical practice across Europe, the European Association of Cardiovascular Imaging Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of echocardiography, advanced imaging modalities, heart valve clinics, and heart valve teams was explored. METHODS AND RESULTS: A total of 61 responders, mainly from tertiary centres or university hospitals, from 26 different countries responded to the survey, which consisted of 22 questions. For most questions related to echocardiography and advanced imaging, the answers were relatively homogeneous and demonstrated good adherence to current recommendations. In particular, the centres used a multi-parametric echocardiographic approach and selected the effective regurgitant orifice and vena contracta width as their preferred assessments. 2D measurements are still the most widely used parameters to assess left ventricular structure; however, the majority use 3D trans-oesophageal echocardiography (TOE) to evaluate valve morphology in severe MR. The majority of centres reported the onsite availability and clinical use of ergometric stress echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) imaging. Heart valve clinics and heart valve teams were also widely prevalent. CONCLUSION: Consistent with current guidelines, echocardiography (transthoracic echocardiography and TOE) remains the first-line and central imaging modality for the assessment of MR although the complementary use of 3D TOE, CCT, and CMR appears to be growing. Heart valve clinics and heart valve teams are now widely prevalent.

Impact of symptom-to-reperfusion-time on transmural infarct extent and left ventricular strain in patients with ST-segment elevation myocardial infarction: a 3D view on the wavefront phenomenon.

AIMS: We examined the association between the symptom-to-reperfusion-time and cardiovascular magnetic resonance (CMR)-derived global strain parameters and transmural infarct extent in ST-segment elevation myocardial infarction (STEMI) patients. METHODS AND RESULTS: The study included 108 STEMI patients who underwent successful primary percutaneous coronary intervention (PPCI). Patients were categorized according to the median symptom-to-reperfusion-time: shorter (<160 min, n = 54) and longer times (>160 min, n = 54). CMR was performed 2-7 days after PPCI and at 1 month. CMR cine imaging was performed for functional assessment and late gadolinium enhancement to evaluate transmural infarct extent. Myocardial feature-tracking was used for strain analysis. Groups were comparable in relation to incidence of LAD disease and pre- and post-PPCI thrombolysis in myocardial infarction (TIMI) flow grades. The mean transmural extent score at follow-up was lower in patients with shorter reperfusion time (P < 0.01). Both baseline and follow-up maximum transmural extent scores were smaller in patients with shorter reperfusion time (P = 0.03 for both). Patients with shorter reperfusion time had more favourable global left ventricular (LV) circumferential strain (baseline, P = 0.049; follow-up, P = 0.01) and radial strain (baseline, P = 0.047; follow-up, P < 0.01), whilst LV longitudinal strain appeared comparable for both baseline and follow-up (P > 0.05 for both). In multi-variable regression analysis including all three strain directions, baseline LV circumferential strain was independently associated with the mean transmural extent score at follow-up (ß=1.89, P < 0.001). CONCLUSION: In STEMI patients, time-to-reperfusion was significantly associated with smaller transmural extent of infarction and better LV circumferential and radial strain. Moreover, infarct transmurality and residual LV circumferential strain are closely linked.

Preoperative Weight Gain Is Not Related to Lower Postoperative Weight Loss, But to Lower Total Weight Loss up to 3 Years After Bariatric-Metabolic Surgery.

INTRODUCTION: Weight loss prior to bariatric-metabolic surgery (BMS) is recommended in most bariatric centers. However, there is limited high-quality evidence to support mandatory preoperative weight loss. In this study, we will evaluate whether weight gain prior to primary BMS is related to lower postoperative weight loss. METHODS: A retrospective analysis of prospectively collected data was performed. Preoperative weight loss (weight loss from start of program to day of surgery), postoperative weight loss (weight loss from day of surgery to follow-up), and total weight loss (weight loss from start of program to follow-up) were calculated. Five groups were defined based on patients' preoperative weight change: preoperative weight loss of >5 kg (group I), 3-5 kg (group II), 1-3 kg (group III), preoperative stable weight (group IV), and preoperative weight gain >1 kg (group V). Linear mixed models were used to compare the postoperative weight loss between group V and the other four groups (I-IV). RESULTS: A total of 1928 patients were included. Mean age was 44 years, 78.6% were female, and preoperative BMI was 43.7 kg/m2. Analysis showed significantly higher postoperative weight loss in group V, compared to all other groups at 12, 24, and 36 months follow-up. Up to three years follow-up, highest total weight loss was observed in group I. CONCLUSION: Weight gain before surgery should not be a reason to withhold a bariatric-metabolic operation. However, patients with higher preoperative weight loss have higher total weight loss. Therefore, preoperative weight loss should be encouraged prior to bariatric surgery.

The diagnostic performance of quantitative flow ratio and perfusion imaging in patients with prior coronary artery disease.

AIMS: In chronic coronary syndrome (CCS) patients with documented coronary artery disease (CAD), ischaemia detection by myocardial perfusion imaging (MPI) and an invasive approach are viable diagnostic strategies. We compared the diagnostic performance of quantitative flow ratio (QFR) with single-photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (CMR) in patients with prior CAD [previous percutaneous coronary intervention (PCI) and/or myocardial infarction (MI)]. METHODS AND RESULTS: This PACIFIC-2 sub-study evaluated 189 CCS patients with prior CAD for inclusion. Patients underwent SPECT, PET, and CMR followed by invasive coronary angiography with fractional flow reserve (FFR) measurements of all major coronary arteries (N = 567), except for vessels with a sub-total or chronic total occlusion. Quantitative flow ratio computation was attempted in 488 (86%) vessels with measured FFR available (FFR ≤0.80 defined haemodynamically significant CAD). Quantitative flow ratio analysis was successful in 334 (68%) vessels among 166 patients and demonstrated a higher accuracy (84%) and sensitivity (72%) compared with SPECT (66%, P < 0.001 and 46%, P = 0.001), PET (65%, P < 0.001 and 58%, P = 0.032), and CMR (72%, P < 0.001 and 33%, P < 0.001). The specificity of QFR (87%) was similar to that of CMR (83%, P = 0.123) but higher than that of SPECT (71%, P < 0.001) and PET (67%, P < 0.001). Lastly, QFR exhibited a higher area under the receiver operating characteristic curve (0.89) than SPECT (0.57, P < 0.001), PET (0.66, P < 0.001), and CMR (0.60, P < 0.001). CONCLUSION: QFR correlated better with FFR in patients with prior CAD than MPI, as reflected in the higher diagnostic performance measures for detecting FFR-defined, vessel-specific, significant CAD.

Left atrial sphericity in relation to atrial strain and strain rate in atrial fibrillation patients.

PURPOSE: Left atrial (LA) sphericity is a novel, geometry-based parameter that has been used to visualize and quantify LA geometrical remodeling in patients with atrial fibrillation (AF). This study examined the association between LA sphericity, and LA longitudinal strain and strain rate measured by feature-tracking in AF patients. METHODS: 128 AF patients who underwent cardiovascular magnetic resonance (CMR) imaging in sinus rhythm prior to their pulmonary vein isolation (PVI) procedure were retrospectively analyzed. LA sphericity was calculated by segmenting the LA (excluding the pulmonary veins and the LA appendage) on a 3D contrast enhanced MR angiogram and comparing the resulting shape with a perfect sphere. LA global reservoir strain, conduit strain, contractile strain and corresponding strain rates were derived from cine images using feature-tracking. For statistical analysis, Pearson correlations, multivariable logistic regression analysis, and Student t-tests were used. RESULTS: Patients with a spherical LA (dichotomized by the median value) had a lower reservoir strain and conduit strain compared to patients with a non-spherical LA (-15.4 ± 4.2% vs. -17.1 ± 3.5%, P = 0.02 and - 8.2 ± 3.0% vs. -9.5 ± 2.6%, P = 0.01, respectively). LA strain rate during early ventricular diastole was also different between both groups (-0.7 ± 0.3s- 1 vs. -0.9 ± 0.3s- 1, P = 0.001). In contrast, no difference was found for LA contractile strain (-7.2 ± 2.6% vs. -7.6 ± 2.2%, P = 0.30). CONCLUSIONS: LA passive strain is significantly impaired in AF patients with a spherical LA, though this relation was not independent from LA volume.

Oral ω-3 PUFA supplementation modulates inflammation in adipose tissue depots in morbidly obese women: A randomized trial.

OBJECTIVES: Obesity is characterized by local and systemic low-grade inflammatory responses. Adipose tissue macrophages (ATM) play decisive roles in inflammation, insulin signaling, and various metabolic dysfunctions. Diets enriched with ω-3 polyunsaturated fatty acids (PUFAs) have been shown to improve health and mitigate pathologic conditions. However, the effects of ω-3 PUFA on adipose tissue inflammation, ATM number, and phenotype are poorly defined in human obesity. The aim of this study was to examine differences in expression of metabolic-inflammatory markers in omental, mesenteric, and subcutaneous fat depots of obese women supplemented with ω-3 PUFAs for 4 wk compared with a low-calorie diet before bariatric surgery. METHODS: In a randomized controlled trial, inflammatory markers in the abdominal adipose tissue and the systemic response in obese women were studied. Patients were treated with a 2-wk low-calorie diet (LCD) or a 4-wk ω-3 PUFA-enriched diet (920 mg eicosapentaenoic acid, 760 mg docosahexaenoic acid daily) before laparoscopic bypass surgery. Omental, mesenteric, and subcutaneous adipose tissue biopsies were collected during surgery and analyzed for quantity and phenotype of ATMs, and profiled for adipokines, cytokines, and signal transduction molecules. RESULTS: The chronic inflammatory state characterized by ATM markers was mostly improved by ω-3 PUFAs in visceral adipose tissue. We observed a decreased expression of CD45, CCL2, and CD68, indicating a lower inflammatory state. In patients with type 2 diabetes, ω-3 PUFAs lowered the expression of Netrin-1. CONCLUSIONS: Compared with an LCD, a diet enriched with ω-3 PUFAs influences the inflammatory state in different adipose tissue depots, by affecting markers of adipose tissue inflammation, macrophage phenotype, and retention. However, this was not reflected in clinical parameters such as insulin resistance and inflammatory cytokines. Subcutaneous adipose tissue and visceral adipose tissue have different responses to an LCD or a ω-3 PUFA-enriched diet. The presence of diabetes modifies the expression of inflammatory markers.

The Impact of Reoperations Following Bariatric Surgery on Mid-term Outcomes.

PURPOSE: With the obesity epidemic, the number of bariatric procedures is increasing, and although considered relatively safe, major postoperative complications still occur. In cancer surgery, major complications such as reoperations have been associated with deteriorated mid/long-term outcomes. In obesity surgery, the effects of reoperations on postoperative weight loss and associated comorbidities remain unclear. The aim of this study was to assess mid-term weight loss and comorbidities following early reoperations in obesity surgery. METHODS: A population-based cohort study was performed within the Dutch Audit for Treatment of Obesity (DATO), including all patients that underwent a primary gastric bypass procedure or sleeve gastrectomy. Follow-up data was collected up until 5 years postoperatively on percentage total weight loss (%TWL) and comorbidities. RESULTS: A total of 40,640 patients underwent a gastric bypass procedure or sleeve gastrectomy between 2015 and 2018. Within this cohort, 709 patients (1.7%) suffered a major complication requiring reoperation within 30 days. %TWL at 24 months was 33.1 ± 9.2 in the overall population, versus 32.9 ± 8.7 in the patients who underwent a reoperation (p=0.813). Both analysis per year and Cox regression techniques revealed no differences in long-term follow-up regarding percentage TLW, and weight loss success rates (%TWL>20%) in patients who underwent a reoperation compared to patients without reoperation. At 5 years, the availability of follow-up data was low. No differences were observed in the remission of comorbidities. DISCUSSION: Major complications requiring reoperation within 30 days of gastric bypass surgery or sleeve gastrectomy did not affect long-term outcomes with regard to weight loss or remission of comorbidities.

Left atrial strain is associated with arrhythmia recurrence after atrial fibrillation ablation: Cardiac magnetic resonance rapid strain vs. feature tracking strain.

PURPOSE: The present study assesses different left atrial (LA) strain approaches in relation to atrial fibrillation (AF) recurrence after ablation and compares LA feature tracking (FT) strain to novel rapid LA strain approaches in AF patients. METHODS: This retrospective single-center study comprised of 110 prospectively recruited AF patients who underwent cardiac magnetic resonance (CMR) imaging in sinus rhythm prior to their first pulmonary vein isolation ablation. LA rapid strain (long axis strain and atrioventricular (AV)-junction strain), LA FT strain, and LA volumes were derived from 2-chamber and 4-chamber cine images. AF recurrence was followed up for 12 months using either 12­lead ECGs or rhythm Holter monitoring. RESULTS: Arrhythmia recurrence was observed in 39 patients (36%) after the 90-day blanking period, occurring at a median of 181 (122-286) days. LA long axis strain, AV-junction strain, and FT strain were all more impaired in patients with AF recurrence compared to patients without AF recurrence (long axis strain: P < 0.01; AV-junction strain: P < 0.001; FT strain: P < 0.01, respectively). Area under the curve (AUC) values for LA remodeling parameters in association with AF recurrence were 0.68 for long axis strain, 0.68 for AV-junction strain, 0.66 for FT strain, 0.66 for LA volume index. Phasic FT LA strain demonstrated that contractile strain had the highest AUC (0.70). CONCLUSION: Both LA rapid strain and LA FT strain are associated with arrhythmia recurrence after ablation in AF patients. LA rapid strain can be a convenient and reproducible alternative for LA FT strain to assess LA function in clinical practice.

Effect of ticagrelor and prasugrel on remote myocardial inflammation in patients with acute myocardial infarction with ST-elevation: a CMR T1 and T2 mapping study.

PURPOSE: Acute myocardial ischaemia triggers a non-specific inflammatory response of remote myocardium through the increase of plasma concentrations of acute-phase proteins, which causes myocardial oedema. As ticagrelor has been shown to significantly decrease circulating levels of several pro-inflammatory cytokines in patients after acute myocardial infarction with ST-elevation (STEMI), we sought to investigate a potential suppressive effect of ticagrelor over prasugrel on cardiac magnetic resonance (CMR) T1 and T2 values in remote myocardium. METHODS: Ninety STEMI patients were prospectively included and randomised to receive either ticagrelor or prasugrel maintenance treatment after successful primary percutaneous coronary intervention. Patients underwent CMR after 2-7 days. The protocol included long and short axis cine imaging, T1 mapping, T2 mapping and late gadolinium enhancement imaging. RESULTS: After excluding 30 patients due to either missing images or insufficient quality of the T1 or T2 maps, 60 patients were included in our analysis. Of those, 29 patients were randomised to the ticagrelor group and 31 patients to the prasugrel group. In the remote myocardium, T1 values did not differ between groups (931.3 [919.4-950.4] ms for ticagrelor vs. 932.6 [915.5-949.2] ms for prasugrel (p = 0.94)), nor did the T2 values (53.8 ± 4.6 ms for ticagrelor vs. 53.7 ± 4.7 ms for prasugrel (p = 0.86)). Also, in the infarcted myocardium, T1 and T2 values did not differ between groups. CONCLUSION: In revascularised STEMI patients, ticagrelor maintenance therapy did not show superiority over prasugrel in preventing early remote myocardial inflammation as assessed by CMR T1 and T2 mapping.

The Dynamic Relationship Between Invasive Microvascular Function and Microvascular Injury Indicators, and Their Association With Left Ventricular Function and Infarct Size at 1-Month After Reperfused ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: The invasive microvascular function indices, coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR), exhibit a dynamic pattern after ST-segment-elevation myocardial infarction. The effects of microvascular injury on the evolution of the microvascular function and the prognostic significance of the evolution of microvascular function are unknown. We investigated the relationship between the temporal changes of CFR and IMR, and cardiovascular magnetic resonance-derived microvascular injury characteristics in reperfused ST-segment-elevation myocardial infarction patients, and their association with 1-month left ventricular ejection fraction and infarct size (IS). METHODS: In 109 ST-segment-elevation myocardial infarction patients who underwent angiography for primary percutaneous coronary intervention (PPCI) and at 1-month follow-up, invasive assessment of CFR and IMR were performed in the culprit artery during both procedures. Cardiovascular magnetic resonance was performed 2 to 7 days after PPCI and at 1 month and provided assessment of left ventricular ejection fraction, IS, microvascular obstruction, and intramyocardial hemorrhage. RESULTS: CFR and IMR significantly changed over 1 month (both, P<0.001). The absolute IMR change over 1 month (ΔIMR) showed association with both microvascular obstruction and intramyocardial hemorrhage presence (both, P=0.01). ΔIMR differed between patients with/without microvascular obstruction (P=0.02) and with/without intramyocardial hemorrhage (P=0.04) but not ΔCFR for both. ΔIMR demonstrated association with both left ventricular ejection fraction and IS at 1 month (P<0.001, P=0.001, respectively), but not ΔCFR for both. Receiver-operating characteristics curve analysis of ΔIMR showed a larger area under the curve than post-PPCI CFR and IMR, and ΔCFR to be associated with both 1-month left ventricular ejection fraction >50% and extensive IS (the highest quartile). CONCLUSIONS: In reperfused ST-segment-elevation myocardial infarction patients, CFR and IMR significantly improved 1 month after PPCI; the temporal change in IMR is closely related to the presence/absence of microvascular damage and IS. ΔIMR exhibits a stronger association for 1-month functional outcome than post-PPCI CFR, IMR, or ΔCFR.

Effects of adipose tissue-derived mesenchymal stem cells and/or sildenafil citrate in experimental colon anastomosis model.

BACKGROUND: This study aimed to evaluate the healing effects of adipose tissue-derived mesenchymal stem cells (AT-MSC) and sildenafil citrate alone or in combination of colon anastomosis experimental model. METHODS: A total of 40 female Wistar rats were randomly distributed to four groups: Control (without any intervention post-anas-tomosis), stem cell (AT-MSC injection on the anastomosis site), SIL (oral gavage of 10 mg/kg sildenafil citrate), and stem cell + SIL (AT-MSC injection and oral administration of sildenafil citrate) groups. Rats were euthanized 5 days post-anastomosis. Intra-abdominal adhesion status and anastomotic burst pressure were measured to assess anastomotic healing. Hydroxyproline and TNF-α level, neu-trophil leukocyte infiltration, epithelial regeneration, and necrosis in the anastomosis tissue were examined. RESULTS: Anastomosis leakage and anastomosis burst pressure were not different among the groups. Treatment with sildenafil, stem cell, and stem cell + SIL reduced the degree of perianastomotic adhesions compared to control (p<0.05). A significant increase was noted in hydroxyproline in the stem cell and stem cell + SIL groups (p=0.001). AT-MSC injection alone or in combination with sildenafil citrate reduced the TNF-α concentration at the anastomosis site (p=0.001). Histopathological examination revealed that all treatments enhanced the clearance of the necrotic debris, reduced leukocytes infiltration, and accelerated the retraction of anastomo-sed ends except control (p=0.001). Epithelial regeneration was more pronounced in the stem cell group than other groups (p=0.001). Macrophage density was lower in groups treated with the SIL or stem cell groups than the control and stem cell + SIL groups (p=0.001). CONCLUSION: Sildenafil citrate and/or AT-MSC in the anastomosed rats promoted the anastomosis healing that was more pro-nounced in groups receiving stem cell injections.

EACVI survey on the multi-modality imaging assessment of the right heart.

AIMS: The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the use of different cardiac imaging modalities for the evaluation of the right heart. METHODS AND RESULTS: Delegates from 250 EACVI registered centres were invited to participate in a survey which was also advertised on the EACVI bulletin and on social media. One hundred and thirty-eight respondents from 46 countries across the world responded to the survey. Most respondents worked in tertiary centres (79%) and echocardiography was reported as the commonest imaging modality used to assess the right ventricle (RV). The majority of survey participants (78%) included RV size and function in >90% of their echocardiographic reports. The RV basal diameter obtained from the apical four-chamber view and the tricuspid annular plane systolic excursion were the commonest parameters used for the echocardiographic assessment of RV size and function as reported by 82 and 97% respondents, respectively. Survey participants reported arrhythmogenic cardiomyopathy as the commonest condition (88%) where cardiac magentic resonance (CMR) imaging was used for right heart assessment. Only 52% respondents included RV volumetric and ejection fraction assessments routinely in their CMR reports, while 30% of respondents included these parameters only when RV pathology was suspected. Finally, 73% of the respondents reported pulmonary hypertension as the commonest condition where right heart catheterization was performed. CONCLUSION: Echocardiography remains the most frequently used imaging modality for the evaluation of the right heart, while the use of other imaging techniques, most notably CMR, is increasing.

Association of left ventricular flow energetics with remodeling after myocardial infarction: New hemodynamic insights for left ventricular remodeling.

BACKGROUND: Myocardial infarction leads to complex changes in left ventricular (LV) hemodynamics. It remains unknown how four-dimensional acute changes in LV-cavity blood flow kinetic energy affects LV-remodeling. METHODS AND RESULTS: In total, 69 revascularised ST-segment elevation myocardial infarction (STEMI) patients were enrolled. All patients underwent cardiovascular magnetic resonance (CMR) examination within 2 days of the index event and at 3-month. CMR examination included cine, late gadolinium enhancement, and whole-heart four-dimensional flow acquisitions. LV volume-function, infarct size (indexed to body surface area), microvascular obstruction, mitral inflow, and blood flow KEi (kinetic energy indexed to end-diastolic volume) characteristics were obtained. Adverse LV-remodeling was defined and categorized according to increase in LV end-diastolic volume of at least 10%, 15%, and 20%. Twenty-four patients (35%) developed at least 10%, 17 patients (25%) at least 15%, 11 patients (16%) at least 20% LV-remodeling. Demographics and clinical history were comparable between patients with/without LV-remodeling. In univariable regression-analysis, A-wave KEi was associated with at least 10%, 15%, and 20% LV-remodeling (p = 0.03, p = 0.02, p = 0.02, respectively), whereas infarct size only with at least 10% LV-remodeling (p = 0.02). In multivariable regression-analysis, A-wave KEi was identified as an independent marker for at least 10%, 15%, and 20% LV-remodeling (p = 0.09, p < 0.01, p < 0.01, respectively), yet infarct size only for at least 10% LV-remodeling (p = 0.03). CONCLUSION: In patients with STEMI, LV hemodynamic assessment by LV blood flow kinetic energetics demonstrates a significant inverse association with adverse LV-remodeling. Late-diastolic LV blood flow kinetic energetics early after acute MI was independently associated with adverse LV-remodeling.

Risk factors for postoperative bleeding in bariatric surgery.

BACKGROUND: Postoperative bleeding remains a relatively common complication following bariatric surgery and may lead to morbidity and even mortality. OBJECTIVE: To develop a prediction model to identify patients at risk for postoperative bleeding. SETTING: Rode Kruis Ziekenhuis, Beverwijk, the Netherlands. Based on Dutch nationwide obesity audit data. METHODS: Patients undergoing primary bariatric surgery were selected from January 2015 to December 2020 from the Dutch Audit for Treatment of Obesity. The primary outcome was postoperative bleeding within 30 days. Assessed predictors included patient factors and operative data. A prediction model was developed using backward stepwise logistic regression. Internal validation was performed using bootstrapping techniques. RESULTS: A total of 59,055 patients were included; 13,399 underwent a sleeve gastrectomy, and 45,656 underwent a gastric bypass procedure. Postoperative bleeding occurred in 1.5%. The following predictors were identified: male patients (odds ratio [OR] = 1.40; 95% confidence interval [CI]: 1.21-1.63), patients >45 years of age (OR = 1.50; 95% CI: 1.29-1.76), body mass index <40 kg/m2 (OR = 1.22; 95% CI: 1.06-1.41), cardiovascular disease (OR = 1.36; 95% CI: 1.17-1.57), and sleeve gastrectomy (OR = 1.43; 95% CI: 1.24-1.67). Area under the curve for the model was .612. Following bootstrapping for internal validation, a correction of .9817 was applied. CONCLUSION: A clinical decision rule was designed to assess the risk of postoperative bleeding in patients undergoing bariatric surgery. If 3 or more risk factors are present, there is an increased risk for postoperative bleeding. The model can aid in clinical decision-making: implementing extra preventative measures in high-risk patients. External validation is needed to further develop the model.

Functional stress imaging to predict abnormal coronary fractional flow reserve: the PACIFIC 2 study.

AIMS: The diagnostic performance of non-invasive imaging in patients with prior coronary artery disease (CAD) has not been tested in prospective head-to-head comparative studies. The aim of this study was to compare the diagnostic performance of qualitative single-photon emission computed tomography (SPECT), quantitative positron emission tomography (PET), and qualitative magnetic resonance imaging (MRI) in patients with a prior myocardial infarction (MI) or percutaneous coronary intervention (PCI). METHODS AND RESULTS: In this prospective clinical study, all patients with prior MI and/or PCI and new symptoms of ischaemic CAD underwent 99mTc-tetrofosmin SPECT, [15O]H2O PET, and MRI, followed by invasive coronary angiography with fractional flow reserve (FFR) in all coronary arteries. All modalities were interpreted by core laboratories. Haemodynamically significant CAD was defined by at least one coronary artery with an FFR ≤0.80. Among the 189 enrolled patients, 63% had significant CAD. Sensitivity was 67% (95% confidence interval 58-76%) for SPECT, 81% (72-87%) for PET, and 66% (56-75%) for MRI. Specificity was 61% (48-72%) for SPECT, 65% (53-76%) for PET, and 62% (49-74%) for MRI. Sensitivity of PET was higher than SPECT (P = 0.016) and MRI (P = 0.014), whereas specificity did not differ among the modalities. Diagnostic accuracy for PET (75%, 68-81%) did not statistically differ from SPECT (65%, 58-72%, P = 0.03) and MRI (64%, 57-72%, P = 0.052). Using FFR < 0.75 as a reference, accuracies increased to 69% (SPECT), 79% (PET), and 71% (MRI). CONCLUSION: In this prospective head-to-head comparative study, SPECT, PET, and MRI did not show a significantly different accuracy for diagnosing FFR defined significant CAD in patients with prior PCI and/or MI. Overall diagnostic performances, however, were discouraging and the additive value of non-invasive imaging in this high-risk population is questionable.

Mitral regurgitation quantified by CMR 4D-flow is associated with microvascular obstruction post reperfused ST-segment elevation myocardial infarction.

OBJECTIVES: Mitral regurgitation (MR) and microvascular obstruction (MVO) are common complications of myocardial infarction (MI). This study aimed to investigate the association between MR in ST-elevation MI (STEMI) subjects with MVO post-reperfusion. STEMI subjects undergoing primary percutaneous intervention were enrolled. Cardiovascular magnetic resonance (CMR) imaging was performed within 48-hours of initial presentation. 4D flow images of CMR were analysed using a retrospective valve tracking technique to quantify MR volume, and late gadolinium enhancement images of CMR to assess MVO. RESULTS: Among 69 patients in the study cohort, 41 had MVO (59%). Patients with MVO had lower left ventricular (LV) ejection fraction (EF) (42 ± 10% vs. 52 ± 8%, P < 0.01), higher end-systolic volume (98 ± 49 ml vs. 73 ± 28 ml, P < 0.001) and larger scar volume (26 ± 19% vs. 11 ± 9%, P < 0.001). Extent of MVO was associated with the degree of MR quantified by 4D flow (R = 0.54, P = 0.0003). In uni-variate regression analysis, investigating the association of CMR variables to the degree of acute MR, only the extent of MVO was associated (coefficient = 0.27, P = 0.001). The area under the curve for the presence of MVO was 0.66 (P = 0.01) for MR > 2.5 ml. We conclude that in patients with reperfused STEMI, the degree of acute MR is associated with the degree of MVO.