An evaluation of dual source computed tomography used with the de Weert classification to detect vulnerable plaque, using IVUS virtual histology as a standard of reference.

BACKGROUND: One of the main risk factors for cerebral ischemic events is atherosclerotic disease of the internal carotid artery (ICA). Nowadays, increasing attention is being paid to the relationship between the morphological features of atherosclerotic plaque and the occurrence of stroke. Several studies have demonstrated that the presence of specific vulnerable plaque types, with a large lipid core and thin fibrous cap, can be used as an independent risk predictor of cerebral ischemic events. OBJECTIVES: The present study is an attempt to develop the method of plaque surface morphology assessment presented by de Weert et al. by correlating the results of Dual Source Computed Tomography (DSCT) with those from intravascular ultrasound virtual histology (IVUS-VH). MATERIAL AND METHODS: A group of 30 symptomatic patients (13 men and 17 women; 72 ± 9 years) with ICA stenosis suspected on the basis of ultrasound imaging (US) and confirmed to be above 70% in DSCT underwent intravascular ultrasound (IVUS) imaging. RESULTS: The results of DSCT were categorized according to the de Weert classification. There were 13 cases (43%) with smooth wall surfaces, 10 cases (33%) with discreet wall irregularities, and seven cases (23%) with incursions of contrast, indicating the presence of ulceration. In the IVUS-VH examinations, 4 out of 30 cases (13%) were identified as having adaptive intimal thickening (AIT), 4 (13%) as showing pathological intimal thickening (PIT), 6 (20%) with fibroatheromas (FA), six (20%) with fibrocalcific plaque (FCa), and 10 (33%) as having thin-cap fibroatheroma (TCFA), which is high-risk plaque. Comparing the above results showed that all the patients with confirmed wall ulceration in DSCT were characterized as having high-risk plaque in IVUS-VH. CONCLUSIONS: Using DSCT with the de Weert classification of plaque surface morphology makes reliable detection of ulcerations possible; therefore, this could become a significant new technique to improve current imaging protocols for patients with a high risk of ischemic cerebrovascular events.

Analysis of Soluble Molecular Fibronectin-Fibrin Complexes and EDA-Fibronectin Concentration in Plasma of Patients with Atherosclerosis.

Atherosclerosis, a chronic vascular disease, leads to molecular events bound with interplaying processes of inflammation and coagulation. In the present study, fibronectin (FN), FN containing extra domain A (EDA-FN), frequency of occurrence, and relative amounts of soluble plasma FN-fibrin complexes were analyzed in 80 plasma samples of patients suspected of coronary artery disease based on clinical evaluation and changes in arteries found by computed tomographic coronary angiography. The study showed that in the plasma of the patients' group with high risk of coronary artery disease EDA-FN concentration was significantly higher (3.5 ± 2.5 mg/L; P < 0.025) and the molecular FN-fibrin complexes of 1000 kDa and higher occurred more often than in the groups of patients with mild risk of coronary artery disease and the normal age-matched. The increased level of EDA-FN and occurrence of FN-fibrin complexes could have a potential diagnostic value in the diagnosis and management of patients with coronary artery disease.

Anomalous origin of the coronary artery from the wrong coronary sinus evaluated with computed tomography: "high-risk" anatomy and its clinical relevance.

OBJECTIVE: The aim of the study was to assess coronary arteries arising from the wrong coronary sinus, including CT-evaluated high-risk anatomic features, clinical symptoms and cardiac events during follow-up. METHODS: A total of 7,115 patients scheduled for 64-slice or dual-source cardiac CT were screened for the presence of isolated anomalous origin of the coronary artery from the wrong coronary sinus. RESULTS: Anomalous origin of the coronary artery was found in 54 (0.76 %) patients (29 men, 25 women, mean age 60.9 ± 11.6 years). Sixteen (30 %) patients with abnormal right coronary origin (ARCA) more commonly had a slit-like orifice (15 vs. 3; p < 0.001), intramural course (15 vs. 3; p < 0.001) and interarterial course (11 vs. 0; p < 0.001) than 22 (41 %) and 13 (24 %) individuals with abnormal circumflex artery (ALCx) and left coronary artery (ALCA) origin, respectively. Patients with ALCA presented less frequently with chest pain than subjects with ARCA and ALCx (25 vs. 3; p = 0.03). Patients with ARCA tended to show higher occurrence of cardiac events in the follow-up than individuals with ALCA and ALCx (5 vs. 4; p = NS). CONCLUSIONS: High-risk anatomy features are most common in patients with ARCA and these patients also have higher prevalence of chest pain and cardiac events in the follow-up than individuals with ALCA and ALCx. KEY POINTS: • Multislice computed tomography enables detection and evaluation of the coronary artery anomalies. • Anomalous anatomy of the coronary artery potentially influences the prevalence of adverse events. • Adverse events tend to be most common in anomalous right coronary arteries.

[Dual source computed tomography in analysis of significance and morphology carotid plaques]. / Dwuzródlowa wielorzedowa tomografia komputerowa w ocenie morfologii i istotnosci blaszek miazdzycowych tetnic szyjnych.

One of the most common causes of stroke is carotid atherosclerosis, stroke affects about 60 thousand Polish people each year and about 27% of them die within a year. About 72%-86% are ischemic strokes, whereas intracerebral or subarachnoid haemorrhages account for about 9-18% of strokes. Stroke is the third most common cause of death worldwide, after heart disease and cancer, and the most often cause of chronic disability in people over 40. Carotid atherosclerosis is one of the most important stroke risk factors. The degree of stenosis is a standard parameter usually used in risk assessment. It was shown that patients with stenosis greater than 70% undergoing endarterectomy achieve the best results in reducing the risk of stroke compared with pharmacotherapy. However, it was found that in the general population of people over 64 the stenosis greater than 70% occurred in 10% of patients, while changes below 70% were very common and appeared in 70% of men and 60% of women. For this reason, the importance of atherosclerotic plaque morphology in the risk assessment is growing. Histopathological and ultrasound (intravascular ultrasound) morphological changes in the composition of the atherosclerotic plaque lead to the creation of the vulnerable plaque concept. Stroke risk seems to be connected with certain morphological features of the plaque, such as thin fibrous cap, lipid core, or ulceration. Ulceration is especially important, as 30% of those patients develop neurological symptoms within 2 years. On the other hand strong plaque calcification, particularly superficial, appears to pose lower risk. Ultrasound imaging of carotid arteries is currently the most widely used non-invasive diagnostic method for detecting and assessing the extent of carotid atherosclerosis. However, apart from undeniable advantages it also has its limitations such as the scope of the imaging and lower sensitivity and specificity in the evaluation of carotid stenosis in relation to magnetic resonance imaging and computed tomography (CT) as showed in metaanalyses from multicenter research (e.g. Chapel et al. metaanalysis). Previous studies using CT demonstrated the suitability of this method in the evaluation of morphology and significance of carotid arteries stenosis. Recent introduction of dual source multidetector computed tomography (DSCT) is a next technological step increasing the usefulness of CT in the assessment of plaque morphology. Due to simultaneous operation of 2 lamps the DSCT uses two concurrent X-ray sources (80 kv and 80 kV or 120 kV or 140 kV) to obtain different radiation absorption coefficients for a given tissue (in Hounsfield units). This allows for better tissue differentiation and advanced image processing, e.g. easy removal of bone parts for better visualization of vascular areas. This method also facilitates more accurate visualization of the lipid core and ulcerations. However, it should be emphasized that still relatively low spatial resolution of this method (0.6 mm) is a serious limitation to an accurate analysis of small structures, such as the components of the atherosclerotic plaque. Therefore, further comparative studies with other invasive diagnostic methods are necessary to improve the imaging protocols.

[The clinical value of computer tomography (CT) of diagnostics of acute thorax pain--a literature review]. / Wartosc kliniczna tomografii komputerowej (CT) w diagnostyce ostrego bólu w klatce piersiowej--przeglad dostepnej literatury.

Conventional angiography of the coronary arteries is a standard in heart and coronary arteries diagnosis, sufficient to choose a treatment method. The introduction of 64-row multidetector computed tomography improved the imaging of coronary arteries by increasing its spatial and temporal resolution. It has been shown that the potential clinical value of CT angiography, including dual source computed tomography (DSCT), is based particularly on the exclusion of coronary artery disease and is now a recognized clinical indication in patients with equivocal stress test results. Detection of hemodynamically insignificant atherosclerotic plaques during CT angiography may be important from the clinical point of view. Rupture of those plaques is the reason of about 60% of acute coronary events. Myocardial infarction with ST-segment elevation is not an indication for CT angiography of the coronary arteries. Acute chest pain is the cause of approximately 6-8% of hospitalizations in the EU and the United States. According to the U.S. data about 50% of patients are admitted to a hospital for observation, and of those only 15% are finally diagnosed with acute coronary syndrome. On the other hand 2-5% of patients are incorrectly diagnosed and discharged home despite the occurrence of ACS. In spite of relatively frequent and easy to recognize symptoms, the subject literature states that diagnosis of more than 1/3 of patients with acute chest pain poses a considerable difficulty in the A&E departments. Problems with proper risk assessment and diagnosis of the disease result in unnecessary hospital admissions, implementation of expensive and often invasive diagnostic methods and generating costs borne by the health care system. There is a need to optimize the minimally invasive diagnostic methods, that allow reliable exclusion of coronary artery disease and acute coronary syndrome. In approximately 10 to 20% of all patients with chest pain neither ST segment elevation nor positive results of enzymatic tests are found, those are patients with low or intermediate risk of acute coronary syndrome. Currently, the most widely used diagnostic method in these patients is a stress test and other diagnostic tests. Coronary angiography and stress tests enable the detection of atherosclerotic lesions, which significantly narrow the artery lumen and reduce the myocardial perfusion. There is therefore the demand for a reliable and minimally invasive imaging method for assessing coronary arteries, which will enable excluding critical coronary artery stenosis or isolating, from a group of medium and low risk patients assessed with routine tests, those who should undergo immediate angiography and invasive treatment. CT angiography allows to assess the severity of coronary atherosclerosis. The possibility of vascular wall and plaque morphology evaluation may have a significant impact on the detection of atherosclerotic lesions of vulnerable character. CT angiography has already been used for the noninvasive assessment of plaque morphology in comparison with the standard, i.e. intracoronary ultrasound-ICUS. Intracoronary ultrasound is the most accurate method for the evaluation of stenosis and plaque morphology, but high costs and invasiveness limit its application. It is necessary to assess the extent to which the multidetector dual source computed tomography may be an alternative for the intracoronary ultrasound (ICUS). Recent years brought about extensive tests of a CT angiography diagnostic algorithm originally called "triple rule-out" (Scheme 1). This method refers to the population of patients without a definitive diagnosis after routine diagnostic tests. It is applied mainly to acute conditions with which a patient reports to the A&E department: myocardial infarction, pulmonary embolism, aortic dissecting aneurysm as well as changes in the chest and ascending aorta and pulmonary arteries. The authors of this paper deem it necessary to conduct further clinical trials on the usefulness and cost-effectiveness of CT angiography in different patient groups.

Infarct size determines myocardial uptake of CD34+ cells in the peri-infarct zone: results from a study of (99m)Tc-extametazime-labeled cell visualization integrated with cardiac magnetic resonance infarct imaging.

BACKGROUND: Effective progenitor cell recruitment to the ischemic injury zone is a prerequisite for any potential therapeutic effect. Cell uptake determinants in humans with recent myocardial infarction are not defined. We tested the hypothesis that myocardial uptake of autologous CD34(+) cells delivered via an intracoronary route after recent myocardial infarction is related to left ventricular (LV) ejection fraction (LVEF) and infarct size. METHODS AND RESULTS: Thirty-one subjects (age, 36-69 years; 28 men) with primary percutaneous coronary intervention-treated anterior ST-segment-elevation myocardial infarction and significant myocardial injury (median peak troponin I, 138 ng/dL [limits, 58-356 ng/dL]) and sustained LVEF depression at ≤45% were recruited. On day 10 (days 7-12), 4.3×10(6) (0.7-9.9×10(6)) (99m)Tc-extametazime-labeled autologous bone marrow CD34(+) cells (activity, 77 MBq [45.9-86.7 MBq]) were administered transcoronarily (left anterior descending coronary artery). (99m)Tc-methoxyisobutyl isonitrile (99(m)Tc-MIBI) single-photon emission computed tomography before cell delivery showed 7 (2-11) (of 17) segments with definitely abnormal/absent perfusion. Late gadolinium-enhanced infarct core mass was 21.7 g (4.4-45.9 g), and infarct border zone mass was 29.8 g (3.9-60.2 g) (full-width at half-maximum, signal intensity thresholding algorithm). One hour after administration, 5.2% (1.7%-9.9%) of labeled cell activity localized in the myocardium (whole-body planar γ scan). Image fusion of labeled cell single-photon emission computed tomography with LV perfusion single-photon emission computed tomography or with cardiac magnetic resonance infarct imaging indicated cell uptake in the peri-infarct zone. Myocardial uptake of labeled cells activity correlated in particular with late gadolinium-enhanced infarct border zone mass (r=0.84, P<0.0001) and with peak troponin I (r=0.76, P<0.001); it also correlated with severely abnormal/absent perfusion segment number (r=0.45, P=0.008) and late gadolinium-enhanced infarct core (r=0.58 and r=0.84, P<0.0001) but not with echocardiography LVEF (r=-0.07, P=0.68) or gated single-photon emission computed tomography LVEF (r=-0.28, P=0.16). The correlation with cardiac magnetic resonance imaging-LVEF was weak (r=-0.38; P=0.04). CONCLUSIONS: This largest human study with labeled bone marrow CD34(+) cell transcoronary transplantation after recent ST-segment-elevation myocardial infarction found that myocardial cell uptake is determined by infarct size rather than LVEF and occurs preferentially in the peri-infarct zone.

Osteoprotegerin, but not osteopontin, as a potential predictor of vascular calcification in normotensive subjects.

We conducted a cross-sectional observation study that included 500 asymptomatic subjects to investigate the relationship between bone metabolism and coronary artery calcification (CAC) in hypertensive conditions. Osteoprotegerin (OPG) and osteopontin (OPN) levels and their associations with hypertension were analyzed to predict CAC in 316 subjects. Multislice computed tomography was used to quantify CAC. Multivariate analysis of variance was used to test the non-interactive effects of hypertension, CAC severity and biomarker levels, and the logistic regression model was applied to predict the risk of CAC. OPG and OPN concentrations were significantly higher in the hypertensive than the normotensive subjects, at 3.0 (2.3-4.0) pmol l(-1) and 51 (21-136) ng ml(-1) vs. 2.4 (2.0-3.0) pmol l(-1) and 41 (13-63) ng ml(-1), respectively. The OPG level, but not OPN level, increased with age (r = 0.29; P = 0.0001). Zero or minimal CAC (<10 Agatston units (AU)) was observed in 63% of the subjects, mild (11-100 AU) in 17%, moderate (101-400 AU) in 12% and severe (401-1000 AU)-to-extensive (>1000 AU) in 8%. In hypertensive subjects, only glomerular filtration rate (GFR) (ß = -0.67) and gender (ß = 0.52) were significant predictors for CAC (R = 0.68). In normotensive patients, GFR (ß = -0.81), gender (ß = 0.48) and log-transformed OPG levels (ß = 0.15) were significant predictors for CAC. OPG levels were associated with an increased risk of CAC in normotensive subjects only (odds ratio: 3.37; 95% confidence interval (1.63-6.57); P = 0.0002). OPG predicted a premature state of vascular calcification in asymptomatic normotensive individuals, and renal function significantly contributed to this process in both hypertensive and normotensive subjects.

Relationship between mitral leaflets angles, left ventricular geometry and mitral deformation indices in patients with ischemic mitral regurgitation: imaging by echocardiography and cardiac magnetic resonance.

UNLABELLED: Chronic ischemic mitral regurgitation (IMR) is associated with a markedly worse prognosis after myocardial infarction (MI).The study aimed to evaluate the relationship between anterior and posterior mitral leaflet angle (MLA) values, left ventricle remodeling and severity of ischaemic mitral regurgitation (IMR). METHODS: Forty-two patients (age 63.5 ± 9.7 years, 36 men) with chronic IMR (regurgitant volume, RV > 20 ml; >6 months after MI) underwent transthoracic echocardiography (TTE) and cardiovascular magnetic resonance (CMR) imaging. Anterior and posterior MLA, determined by echocardiography, were correlated with indices of LV remodeling, mitral apparatus deformation and IMR severity by CMR. The anterior and posterior MLA was 25.41 ± 4.28 and 38.37 ± 8.89° (mean ± SD). In 5 patients (11.9%) the posterior MLA was ≥45°. There was a significant correlation between anterior MLA and RV (r = 0.74, P = 0.01). For patients with RV > 30 ml this correlation was stronger (r = 0.97, P = 0.005) and, in addition, there was a correlation between the RV and posterior MLA (r = 0.90, P = 0.037), between tenting area and posterior MLA (r = 0.90, P = 0.04), and between tenting area and anterior MLA (r = 0.82, P = 0.08). With regard to LV remodeling parameters, there was weaker but significant correlation between posterior MLA and LV end-diastolic volume index (r = 0.35, P = 0.031), LV end-systolic volume index (r = 0.37, P = 0.021), stroke volume (r = 0.35, P = 0.03), sphericity index (r = 0.33, P = 0.041). Anterior MLA correlated with wall motion score index (r = 0.41, P = 0.019). Besides, there was a correlation between posterior MLA and left atrial volume (r = 0.41, P = 0.012). Measurement of anterior and posterior MLA may play an important role in evaluating patients with IMR.

The composition and extent of coronary artery plaque detected by multislice computed tomographic angiography provides incremental prognostic value in patients with suspected coronary artery disease.

Multislice computed tomographic coronary angiography (CTCA) provides accurate noninvasive assessment of coronary artery disease (CAD). However, data on the prognostic value of CTCA in patients with suspected CAD are only beginning to emerge. The aim of the study was to assess the prognostic value of CTCA in patients with suspected CAD. Patients (males = 259, females = 235; mean age 58.2 ± 9.8 years) with suspected CAD who underwent 16- or 64-slice CTCA were followed for 1,308 ± 318 days for cardiac death, nonfatal myocaridal infarction (MI) and late (>90 days after CTCA) revascularization. Patient outcomes were related to clinical and CTCA data. Cox proportional-hazards model was applied in stepwise forward fashion to identify outcome predictors. Coronary artery plaque was found in 340 patients. Cardiac events occurred in 40 patients including cardiac death (n = 9), nonfatal MI (n = 8) and late revascularization (n = 23). A multivariable analysis identified the following independent predictors for adverse cardiac events: obstructive plaque in a proximal coronary artery segment (hazard ratio (HR) 2.73; 95% confidence interval (CI): 1.35-5.54; P = 0.005), the number of segments with noncalcified plaque(s) (HR 1.53 per segment; 95%CI: 1.21-1.92; P < 0.001), the number of segments with mixed plaque(s) (HR 1.56 per segment; 95%CI: 1.27-1.92; P < 0.001) and the number of segments with calcified plaque(s) (HR 1.21 per segment; 95%CI: 1.07-1.37; P = 0.002). In patients with suspected CAD, both the extent and composition of atherosclerotic plaque as determined by CTCA are prognostic of subsequent cardiac events.

Extent of RV dysfunction and myocardial infarction assessed by CMR are independent outcome predictors early after STEMI treated with primary angioplasty.

OBJECTIVES: The aim of this study was to assess the prognostic value of right ventricular (RV) involvement diagnosed by cardiac magnetic resonance (CMR) early after ST-elevation myocardial infarction (STEMI). BACKGROUND: CMR allows accurate and reproducible RV assessment. However, there is a paucity of data regarding the prognostic value of RV involvement detected by CMR early after STEMI. METHODS: Ninety-nine patients (77 men, mean age 57 ± 11 years) who underwent CMR 3 to 5 days after STEMI treated with primary angioplasty were followed for 1,150 ± 337 days for cardiac events (cardiac death, nonfatal myocardial infarction [MI], and hospitalizations due to decompensated heart failure). Cox proportional hazards model was applied in stepwise forward fashion to identify outcome predictors. Event-free survival was estimated by Kaplan-Meier method and compared between groups by the log-rank test. RESULTS: Cardiac events occurred in 34 patients (7 cardiac deaths, 8 MIs, 26 hospitalizations). By multivariable analysis, the independent outcome predictors were left ventricular (LV) MI transmurality index (hazard ratio: 1.03 per 1%; 95% confidence interval: 1.01 to 1.04; p = 0.001), RV ejection fraction (RVEF) (hazard ratio: 1.46 per 10% decrease; 95% confidence interval: 1.05 to 2.02; p = 0.03), and RVMI extent (hazard ratio: 1.50 per each infarcted RV segment; 95% confidence interval: 1.11 to 2.01; p = 0.007). Compared with clinical data (global chi-square = 5.2), LV ejection fraction [LVEF] (global chi-square = 11.1), RVEF (global chi-square = 17.1), LVMI transmural extent (global chi-square = 26.0), and RVMI extent (global chi-square = 34.9) improved outcome prediction in sequential Cox model analysis (p < 0.05 for all steps). RVEF stratified risk in patients with LVEF <40% in whom the 4-year event-free survival was 66.7% for RVEF ≥40% and 40.0% for RVEF <40% (p < 0.05). CONCLUSIONS: The extent of RVMI and RV dysfunction assessed early after STEMI are independent outcome predictors, which provide incremental prognostic value to clinical data, LV systolic function, and infarct burden. Measurement of RVEF may be particularly useful to stratify risk in patients with depressed LV function after STEMI.

Resynchronization therapy transvenous approach in dextrocardia and congenitally corrected transposition of great arteries.

Cardiac resynchronization therapy (CRT) is an acknowledged treatment for advanced heart failure in acquired dilated cardiomyopathy, resistant to pharmacotherapy. Although there are no therapeutic standards regarding heart failure originating from congenital heart defects with systemic right ventricle, a number of CRT implantations by transvenous approach in congenitally corrected transposition of the great arteries (CCTGA) have been reported since 2001, even though none of them expressly referred to a case concomitant with dextrocardia and situs inversus anomaly. We present a 57 year-old patient with dextrocardia and CCTGA, who underwent surgical closure of interatrial and interventricular septal defects at the age of 19, and in whom a VVI pacemaker was subsequently implanted at age 36. A three-lead CRT system was implanted by transvenous approach. Imaging techniques, including multi-slice computed tomography, targeted to pacing system and unusual anatomical relationships were applied. Within a 20-month follow-up, a significant improvement of functional NYHA class, systemic right ventricle ejection fraction and exercise capability were observed. Entirely transvenous CRT system implantation is feasible in patients with dextrocardia and CCTGA, and has substantial potential for long-term benefits.

[Use of magnetic resonance in the diagnostics of ischemic heart disease]. / Zastosowanie rezonansu magnetycznego w diagnostyce choroby niedokrwiennej serca.

The role of magnetic resonance imaging (MRI) as a diagnostic tool of coronary arteries disease has increased over the last years. Cardiac magnetic resonance (CMR) is a preferable tool in assessment of ventricular mass and function, presence and size of post infarct scaring and anomalies of coronary arteries. CMR becomes also a useful method in evaluation of myocardial viability. Examination with gadolinium dye allows for evaluation of myocardial perfusion and viability. The extent of the post infarct late enhancement zone has an important prognostic value in the recovery of the left ventricle function. Dobutamine, adenosine or dypirydamol stress CMR becomes a promising noninvasive diagnostic modality in detection of coronary artery disease. At present coronary arteries magnetic resonance angiography is being developed as well as CMR spectroscopy.

[Assessment of coronary artery stents in computed tomography: state of the art]. / Ocena stentów tetnic wiencowych w tomografii komputerowej: stan obecny.

Percutaneous coronary interventions (PCI) with stent implantation play an important role in the revascularization therapy of coronary artery disease. Introduction of drug eluting stents (DES) diminished problem of restenosis but brought several new major problems like i.e. late stent thrombosis. This makes bare metal stents (BMS) still popular choice for some patients. Coronary-artery-computed-tomography becomes useful device in the noninvasive diagnostics measure of restenosis after PCI. Development of 64-slice computed tomography (CT) enables the noninvasive imaging and evaluation of stents with diameter higher than 3,0 mm and detection of significant restenosis with a low number of false positive results. CT allows with high accuracy to exclude in-stent restenosis among patients with atypical angina, especially those localized in proximal segments of coronary arteries. Future development of CT is needful since evaluation of significant number of examinations remains difficult or impossible due to presence of artifacts.

[Type IV dual left anterior descending coronary artery - a rare congenital coronary artery anomaly. A case report]. / Podwójna lewa tetnica zstepujaca przednia typu IV - rzadko wystepujaca wrodzona anomalia tetnic wiencowych. Opis przypadku.

An extremely rare case of type IV dual left anterior descending coronary artery coexisting with myocardial bridging in a 50-year old Caucasian man with acute coronary syndrome is presented. Emergency cardiac catheterisation revealed no coronary atherosclerotic lesions. The potential causal relationship between the type IV dual left anterior descending coronary artery and myocardial ischaemia was discussed. We also summarised the current knowledge on the epidemiology and clinical significance of dual left anterior descending coronary artery in the adult population.

Delayed perforation of the right ventricle as a complication of permanent cardiac pacing - is following the guidelines always the right choice? Non-standard treatment - a case report and literature review.

A case of a delayed perforation of the right ventricle by the pacemaker lead in a 67-year-old woman is presented. Perforation, mimicking stenocardial symptoms, was incidentally diagnosed on a computed tomography chest scan. Percutaneous lead extraction was successfully performed, with simultaneous implantation of a new pacemaker lead.

Comparison of magnetic resonance feature tracking for strain calculation with harmonic phase imaging analysis.

OBJECTIVES: To compare a steady-state free precession cine sequence-based technique (feature tracking [FT]) to tagged harmonic phase (HARP) analysis for peak average circumferential myocardial strain (epsilon(cc)) analysis in a large and heterogeneous population of boys with Duchenne muscular dystrophy (DMD). BACKGROUND: Current epsilon(cc) assessment techniques require cardiac magnetic resonance-tagged imaging sequences, and their analysis is complex. The FT method can readily be performed on standard cine (steady-state free precession) sequences. METHODS: We compared mid-left ventricular whole-slice epsilon(cc) by the 2 techniques in 191 DMD patients grouped according to age and severity of cardiac dysfunction: group B: DMD patients 10 years and younger with normal ejection fraction (EF); group C: DMD patients older than 10 years with normal EF; group D: DMD patients older than 10 years with reduced EF but negative myocardial delayed enhancement (MDE); group E: DMD patients older than 10 years with reduced EF and positive MDE; and group A: 42 control subjects. Retrospective, offline analysis was performed on matched tagged and steady-state free precession slices. RESULTS: For the entire study population (N = 233), mean FT epsilon(cc) values (-13.3 +/- 3.8%) were highly correlated with HARP epsilon(cc) values (-13.6 +/- 3.4%), with a Pearson correlation coefficient of 0.899. The mean epsilon(cc) of DMD patients determined by HARP (-12.52 +/- 2.69%) and FT (-12.16 +/- 3.12%) was not significantly different (p = NS). Similarly, the mean epsilon(cc) of the control subjects by determined HARP (-18.85 +/- 1.86) and FT (-18.81 +/- 1.83) was not significantly different (p = NS). Excellent correlation between the 2 methods was found among subgroups A through E, except there was no significant difference in strain between groups B and C with FT analysis. CONCLUSIONS: FT-based assessment of epsilon(cc) correlates highly with epsilon(cc) derived from tagged images in a large DMD patient population with a wide range of cardiac dysfunction and can be performed without additional imaging.

Late gadolinium enhancement in cardiovascular magnetic resonance in patients with hypertrophic cardiomyopathy complicated by life-threatening ventricular tachyarrhythmia.

BACKGROUND: Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) has been shown to be associated with ventricular arrhythmias, however, its prognostic role in predicting sudden cardiac death has not yet been established. AIM: To explore a potential relationship between LGE visualised by CMR and life-threatening ventricular tachyarrhythmia in hypertrophic cardiomyopathy (HCM). METHODS: The LGE in CMR was assessed in 55 HCM patients. We compared the frequency and extent of LGE in HCM patients with sustained ventricular tachycardia (VT) or who survived ventricular fibrillation (VF) or sudden death [group VF (+)] versus HCM patients without these tachyarrhythmias [group VF (-)]. There were 14 patients in the VF (+) group and 41 patients in the VF (-) group, and they were followed for a mean period of 37 months. RESULTS: In group VF (+), adequate ICD intervention occurred in 9 patients (8 patients with VF and one patient with sustained VT), and VF arrest occurred in 5 patients (4 patients were resuscitated and one patient had a witnessed sudden death). In group VF (+) all patients had LGE whereas in group VF (-) 85% patients presented this abnormality (p = 0.13). Moreover, there were no statistical differences between groups in the following parameters: age, total left ventricular (LV) mass, maximal LV wall thickness, mass of hyperenhanced myocardium and percent of hyperenhanced myocardium. CONCLUSION: In HCM patients with life-threatening ventricular tachyarrhythmia LGE was both qualitatively and quantitatively comparable with patients without these tachyarrhythmias.

Myocardial perfusion in hypertensive patients with normal coronary angiograms.

BACKGROUND: Pressure-induced left ventricular hypertrophy is one of the mechanisms responsible for an impaired coronary vasodilating capacity leading to myocardial ischemia and angina. The aim of the study was to investigate myocardial perfusion using cardiovascular magnetic resonance in patients with arterial hypertension and a history of chest pain and normal coronary angiography, and to estimate the influence of left ventricular hypertrophy on the parameters of myocardial perfusion. METHODS: The study included 102 patients (mean age 55.4 +/- 7.7 years) with well controlled hypertension and 12 healthy volunteers. In 96 patients, myocardial first-pass perfusion cardiovascular magnetic resonance both at rest and during an infusion of adenosine 140 microg/kg/min was performed. Semiquantitative perfusion analysis was performed by using the upslope of myocardial signal enhancement to derive the myocardial perfusion index and the myocardial perfusion reserve index. The study group was divided according to the presence of left ventricular hypertrophy in the cardiovascular magnetic resonance examination: group with left ventricular hypertrophy (n = 40) and without left ventricular hypertrophy (n = 56). RESULTS: Independent of the presence of left ventricular hypertrophy, there were significant differences in baseline myocardial perfusion index between hypertensive patients and controls (0.13 +/- 0.07 vs. 0.04 +/- 0.01; P < 0.001), and in stress myocardial perfusion index (hypertensive patients 0.21 +/- 0.10 vs. controls 0.09 +/- 0.03; P < 0.001). In hypertensive patients, the myocardial perfusion reserve index was reduced in the mid and apical portions of the left ventricle (1.71 +/- 1.1 vs. 2.52 +/- 0.83; P < 0.02). There was no significant correlation of myocardial perfusion reserve index with left ventricular mass or hypertrophy. CONCLUSION: In patients with mild or moderate hypertension and a history of chest pain with normal coronary angiography, there is regional myocardial perfusion reserve impairment that is independent of the presence of left ventricular hypertrophy and may be a reason for angina.