Computed tomography characteristics of coronary artery atherosclerosis in subjects with lower extremity peripheral artery disease and no cardiac symptoms.

INTRODUCTION:  Computed tomography coronary angiography (CTCA) enables noninvasive evaluation of coronary artery atherosclerosis. However, its value to assess coronary artery disease (CAD) in subjects with lower­extremity peripheral artery disease (PAD) and no cardiac symptoms is unknown. Moreover, the relationship between coronary artery plaque characteristics and severity of peripheral atherosclerosis in this group of patients was not sufficiently elucidated. OBJECTIVES:  The aim of the study was to determine the value of CTCA to assess coronary artery atherosclerosis and to evaluate the relationship between coronary artery plaque characteristics and severity of peripheral atherosclerosis in subjects with lower­extremity PAD and no cardiac symptoms. PATIENTS AND METHODS:  Sixty­five individuals (45 men, 20 women, mean age, 62.5 ±7.6 years) with lower­extremity PAD and no cardiac symptoms underwent CTCA. RESULTS:  CTCA revealed CAD in 56 subjects. Twenty­two had obstructive CAD. The mean ankle-brachial index (ABI) was 0.64 ±0.16. Twenty­six individuals demonstrated abnormal carotid artery intima-media thickness (IMT). ABI lower than median, if compared with ABI equal of higher than median, was associated with a higher proportion of obstructive multivessel to single vessel CAD (8:4 vs. 1:9; P = 0.01) and higher number of coronary artery segments with mixed plaques (2.3 ±2.2 vs. 1.2 ±1.3; P = 0.02). Comparing patients with abnormal and normal IMT, the former demonstrated higher proportion of obstructive multivessel to single-vessel CAD (7:3 vs. 2:10; P = 0.01) and higher number of coronary artery segments with noncalcified (1.9 ±3.2 vs. 0.6 ±1.4; P = 0.04) and mixed plaques (2.3 ±2.1 vs. 1.3 ±1.7; P = 0.049). CONCLUSIONS:  CTCA may be effective to detect CAD in subjects with lower­extremity PAD and no cardiac symptoms. The low ABI and abnormal IMT are associated with more extensive CAD and higher burden of high­risk coronary artery plaques.

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.

Myocardial ischaemia in systemic lupus erythematosus: detection and clinical relevance.

BACKGROUND: Severe cardiovascular complications are among the most important causes of mortality in systemic lupus erythematosus (SLE) patients. AIM: To assess the usefulness of echocardiography, ECG, and coronary artery calcium scoring (CACS) in the detection of myocardial ischaemia in SLE patients compared to single photon emission computerised tomography (SPECT) and to assess their five-year follow-up. METHODS: In 50 consecutive SLE patients (mean age 39.2 ± 12.9 years, 90% female), clinical assessment, resting and exercise ECG and echocardiography, multidetector computed tomography - based CACS and SPECT studies (Tc-99m sestamibi) were performed. Patients were then followed for five years. RESULTS: SPECT revealed perfusion defects in 25 (50%) patients; persistent defects in 18 (36%) and exercise-induced defects in seven (14%) subjects. No typical ischaemic heart disease clinical symptoms, signs of ischaemia in resting ECG, or left ventricular contractility impairment in echocardiography were observed. Signs of ischaemia in exercise ECG were found in 17 (34%) patients. The CACS ranged from 1 to 843.2 (median 23.15), and coronary calcifications were observed in 12 (24%) patients. Compared to the SPECT study, exercise ECG had 68% sensitivity and 100% specificity in detecting myocardial ischaemia, while CACS had only 28% sensitivity and 58% specificity. During follow-up, one patient who showed myocardial perfusion defects and the highest calcium score (843.2) at baseline, developed CCS II class symptoms of myocardial ischaemia. Coronary angiography was not performed because of severe anaemia; the patient died three months later. In two other patients with perfusion defects and calcium deposits at baseline, CCS I class symptoms were observed; coronary angiography showed only thin calcified coronary plaques that were haemodynamically insignificant. CONCLUSIONS: In about half of relatively young, mostly female, SLE patients, SPECT shows myocardial perfusion defects, with coronary calcifications present in one quarter of them. While ECG and echocardiography may not reveal any pathology, ECG exercise test can identify these patients with high specificity. In patients with a negative SPECT, the short-term prognosis is good, while in patients with perfusion defects and coronary calcifications, the clinical symptoms of myocardial ischaemia could occurr. However, at a low calcium score ( < 150), the short-term risk of significant atherosclerosis progression is low.

Influence of chronic inflammation and autoimmunity on coronary calcifications and myocardial perfusion defects in systemic lupus erythematosus patients.

OBJECTIVE: Conventional risk factors for coronary artery disease fail to explain the increased frequency or cardiovascular morbidity in systemic lupus erythematosus (SLE) patients. This study was conducted to determine the possible influence of autoimmune and inflammatory phenomena markers on coronary artery calcifications and myocardial perfusion abnormalities in SLE patients. MATERIALS AND METHODS: Multi-detector computed tomography (MDCT)-based coronary calcium scoring and single photon emission computerized tomography (SPECT) studies (Tc-99m sestamibi) were performed in 60 SLE patients in stable clinical condition, without a prior history of coronary artery disease. Laboratory evaluation included serum C-reactive protein (CRP), complement C3c and C4 components and antiphospholipid antibodies (aPL). The latter included anticardiolipin (aCL) and anti-ß2-glycoprotein I (aß2GPI) antibodies, of both IgG and IgM classes, and lupus anticoagulant (LA) in plasma. RESULTS: SPECT revealed persistent perfusion defects in 22 (36.7%) patients and exercise-induced defects in eight (13.3%), while MDCT revealed coronary calcifications in 15 (25%). Calcium scores ranged from 1 to 843.2 (mean 113.5 ± 259.7). No association was found between conventional coronary artery disease risk factors (obesity, hypertension, tobacco use, hyperlipidaemia, diabetes) nor CRP, C3c or C4 levels and coronary calcifications or myocardial perfusion defects. On the contrary, in patients with these pathologies, augmented autoimmunization was found, reflected by increased aCL IgG and antiß2GPI IgG levels. In patients with aCL IgG >20 RU/ml or antiß2GPI IgG >3 RU/ml, the relative risk of coronary calcification formation was 4.1 compared to patients with normal values. Accordingly, in LA-positive patients the relative risk of coronary calcification formation was 4.4 compared to LA-negative patients. CONCLUSIONS: Conventional risk factors for coronary artery disease as well as markers of an ongoing inflammation did not show any association with perfusion defects and/or coronary artery calcifications in SLE patients. On the contrary, calcified atherosclerotic plaques and myocardial perfusion defects were observed mainly in patients with elevated levels of anticardiolipin and aß2GPI antibodies of the IgG class. It might be speculated that coronary artery calcifications and perfusion defects are a result of antiphospholipid antibodies-induced coronary artery microthrombosis.

Increased levels of bone remodeling biomarkers (osteoprotegerin and osteopontin) in hypertensive individuals.

OBJECTIVES: Osteoprotegerin (OPG) and osteopontin (OPN) are bone metabolism biomarkers which are involved in the regulation of vascular calcification processes and prediction of future adverse cardiac events. DESIGN AND METHODS: OPG, OPN levels and classic risk factors were determined in 130 asymptomatic and hypertensive subjects. Receiver operator characteristic (ROC) analysis was performed and the area under the curve (AUC) was calculated. RESULTS: The hypertensive subjects had elevated OPG, OPN, fibrinogen, CRP and fasting glucose levels in comparison to the normotensive ones. There were significant correlations between age, CRP and OPG. Multiple regression analysis showed that as well as inflammation (CRP), age and hypertension were predictors of increased OPG levels. OPN increase was correlated with CRP and glucose levels. The AUCs were similar for OPG and OPG biomarkers. CONCLUSIONS: Plasma OPG and OPN levels were significantly associated with inflammation and arterial hypertension. They might be useful as additional biomarkers for monitoring endothelial dysfunction and prognosis of cardiovascular diseases.

Beneficial effect of cigarette smoking cessation on fibrin clot properties.

To examine the associations between cigarette smoking and preferable clot properties. Plasma fibrin clots from 21 randomly selected current smokers (n = 7), former smokers (n = 7) and non-smokers (n = 7) were analyzed, using scanning electron microscopy (SEM). With the use of the turbidimetric clotting and lysis assay in plasma, the maximum absorbance (MaxAbs(C), MaxAbs(L)) was measured and lysis time (Lys(50%)) was calculated. Smoking cessation significantly influenced fibrin fiber branching and density. Median fiber diameter was not changed. Lys(50%) was the highest in current smokers and was reduced in former smokers to the non-smoker level (2120 ± 385 versus 1771 ± 122 and 1724 ± 272 s; P = 0.04). Smoking cessation improves fibrin clot architecture which results in the lesser resistance to lysis.

[Severe dilated cardiomyopathy as a complication of well controlled Churg-Strauss syndrome]. / Ciezka kardiomiopatia rozstrzeniowa jako powiklanie lagodnie przebiegajacego zespolu Churga−Strauss.

We present a case of a 42 year-old male with Churg-Strauss syndrome (CSS), who despite clinical remission developed severe dilated cardiomyopathy. Intensified immunosuppression helped to improve heart function. As heart involvement in CSS is very common, and may occur without prior symptoms, magnetic resonance imaging is advisable to identify patients with heart damage and introduce proper treatment.

Randomized transcoronary delivery of CD34(+) cells with perfusion versus stop-flow method in patients with recent myocardial infarction: Early cardiac retention of 99(m)Tc-labeled cells activity.

BACKGROUND: For transcoronary progenitor cells' administration, injections under flow arrest (over-the-wire balloon technique, OTW) are used universally despite lack of evidence for being required for cell delivery or being effective in stimulating myocardial engraftment. Flow-mediated endothelial rolling is mandatory for subsequent cell adhesion and extravasation. METHODS: To optimize cell directing toward the coronary endothelium under maintained flow, the authors developed a cell-delivery side-holed perfusion catheter (PC). Thirty-four patients (36-69 years, 30 men) with primary stent-assisted angioplasty-treated anterior MI (peak TnI 151 [53-356]ng/dL, mean[range]) were randomly assigned to OTW or PC autologous 99Tc-extametazime-labeled bone marrow CD34(+) cells (4.34 [0.92-7.54] × 106) administration at 6-14 days after pPCI (LVEF 37.1 [24-44]%). Myocardial perfusion (99(m)Tc-MIBI) and labeled cells' activity were evaluated (SPECT) at, respectively, 36-48 h prior to and 60 min after delivery. RESULTS: In contrast to OTW coronary occlusions, no intolerance or ventricular arrhythmia occurred with PC cells' administration (P < .001). One hour after delivery, 4.86 [1.7-7.6]% and 5.05 [2.2-9.9]% activity was detected in the myocardium (OTW and PC, respectively, P = .84). Labeled cell activity was clearly limited to the (viable) peri-infarct zone in 88% patients, indicating that the infarct core zone may be largely inaccessible to transcoronary-administered cells. CONCLUSIONS: Irrespective of the transcoronary delivery method, only ≈ 5% of native (i.e., non-engineered) CD34(+) cells spontaneously home to the injured myocardium, and cell retention occurs preferentially in the viable peri-infarct zone. Although the efficacy of cell delivery is not increased with the perfusion method, by avoiding provoking ischemic episodes PC offers a rational alternative to the OTW delivery.

Development, implementation, and multicenter clinical validation of the TeleDICOM--advanced, interactive teleconsultation system.

UNLABELLED: There is a need to make medical diagnosis available to critically ill patients on-site, without the necessity of time-consuming and risky transportation to larger reference hospitals. The teleconsultation of medical images is possible with the use of Internet-based TeleDICOM software developed in Krakow, Poland. Interactive consultation between two or more centers offers real-time voice communication, visualization of synchronized Digital Imaging and Communications in Medicine images, and use of interactive pointers and specific calculation tools. If direct interaction between physicians is not needed, the system can also be used in "offline" mode. In 2006, TeleDICOM was successfully deployed in the John Paul II Hospital in Krakow as well as a dozen other cooperating medical centers throughout southeast Poland. It is used for routine referral for cardiosurgical procedures. Aims of the study were to evaluate the image quality, software stability, constant availability, data transmission speed, and quality of real-time synchronized viewing of the images during the TeleDICOM teleconsultation; to evaluate the clinical utility of the TeleDICOM system; and to analyze the compatibility of TeleDICOM with the storage data formats of various imaging machine manufacturers. The analysis of angiographic offline teleconsultations was based on 918 patients referred remotely for coronary artery bypass grafting (CABG). The echocardiographic teleconsultations were performed during 63 live interactive consultations, several of them were presented to live during medical conferences. Measurement tools of the TeleDICOM software were tested against original measurement tools of echocardiographic machines from four different manufacturers. As a result of TeleDICOM consultation, a CABG decision was made in 806 of 918 patients consulted (87.8%). In remaining 12 patients, medical therapy or percutaneous angioplasty was recommended. CABG was performed in 98.6% of the admitted patients. Treatment decisions were changed after admission in 1.4% of patients-however, in all cases, it was not related to analysis of angiography data but rather to the change of clinical condition of the patients. All medical personnel involved in both offline and interactive teleconsultations judged the system positively in all assessed aspects. Lesser scores were observed only in the centers connected by slower networks. Measurements performed in the ECHO-TeleDICOM module were accurate as compared with those performed on a standard echo-machine (correlation r > 0.980, p < 0.001), independently of the echocardiograph model. CONCLUSION: This study demonstrates that telemedicine can improve patients' management using a clinically effective teleconsultation system. The TeleDICOM system is suited for professional use in the field of cardiovascular disease. It is also prepared for remote live demonstrations of clinical cases during large medical meetings.

[Cardiovascular calcification and five-years mortality in patients on maintenance hemodialysis]. / Zwapnienia w ukladzie sercowo-naczyniowym a 5-letnia smiertelnosc pacjentów leczonych powtarzanymi hemodializami.

The very high cardiovascular mortality and morbidity in hemodialyzed patients (HD) is strongly associated with cardiovascular calcification. The aim of the study was to find the predictors of mortality in HD patients during 5-years observation period. The study group was composed of 64 patients (35 F, 29 M) aged 25-75 years (mean 48.9) hemodialyzed three times a week for 12-275 months (mean 77.8). The levels of hemoglobin, total protein, albumin, Ca, P, Ca x P, iPTH, cholesterol, triglycerides, fibrinogen, insulin, homocysteine, leptin, procalcitonin, CRP, IL-6, TGF-beta, PDGF were assessed and all patients underwent Calcium Score (CS) of coronary arteries (CACS) calculation using MSCT and B-mode ultrasound of carotid arteries for intima-media thickness (CCA-IMT), as well as echocardiographic assessment with LVMI calculation and heart valves evaluation at the start of observation. The self-elaborated Cumulative Calcification Index (CCl) was calculated as a sum of CACS Index according to Rumberger et al. (CS<10-0, 10400 - 3 points); number of calcified plaques in carotid arteries (0-0, 1 - 1, 2 - 2, 3 and more - 3 points) and the number of calcified heart valves. At the start of the study the median value of CCl was 4 and interquartile range 4. Only 2 (3%) patients were free of any type of cardiovascular calcification (CCl =0), 15 (23%) patients had minimal calcification (CCl 1 to 2 points), 33 (52%) average (2 - 6 points) and 14 (22%) patients had severe calcification (CCl>6). 21 (32,8%) patients died during observation period. Patients who died were older (56.9 vs. 45.3 yrs.) and had higher CS at the start (1275 vs. 356), higher CCA-IMT (0.948 vs. 0.687 mm) and CCl (6.15 vs. 3.63) values. Those patients had also higher CRP (0.645 vs. 0.245 mg/dl) and IL-6 (10.16 vs. 4.15 pg/ml) levels (p<0.05). LVMI and mean: hemoglobin, total protein, albumin, Ca, P, Ca x P, iPTH, cholesterol, triglycerides, fibrinogen, insulin, homocysteine, leptin, procalcitonin, TGF-beta as well as PDGF levels did not differ between the groups. In logistic regression model (p<0.00002), among tested parameters only CCl was an independent and statistically significant factor of mortality with OR=1.82 per every point of CCl (p<0.0003). Cardiovascular calcification expressed as CCl confirmed to be a strong predictor of mortality in HD patients.

[Physical activity and subclinical coronary atherosclerosis in asymptomatic middle-aged men]. / Aktywnosc fizyczna a subkliniczna miazdzyca tetnic wiencowych u bezobjawowych mezczyzn w wieku srednim.

INTRODUCTION: Few studies have examined the effect of physical activity (PA) on subclinical atherosclerosis. Those that have been conducted were not based on longitudinal observation of lifestyle and objective measures of cardiorespiratory fitness. AIM: The aim of the study was to assess the influence of PA level on subclinical atherosclerosis in a long-term prospective observation (mean 17.9 +/- 4.21 years) of asymptomatic middle aged-men. METHODS: We studied 27 men with stable high PA level (mean age 57.1 +/- 6.6 years) and 27 pair matched controls with sedentary lifestyle (mean age 56.1 +/- 6.6 years). PA level was assessed by detailed questionnaire based on the CINDI Health Monitor Questionnaire. Objective measurements of aerobic capacity was evaluated by exercise tests. Subclinical atherosclerosis was measured by assessing coronary calcification score (CCS) according to Agatston's method by means of the multi-slice computed tomography. RESULTS: Mean CCS was significantly lower among highly active men than among sedentary controls (28.3 +/- 70.6 vs 211.4 +/- 344.9; respectively, p<0.02). Active men had also more often CCS=0 (15 vs 7 persons). Not even one case of advanced calcification (CCS > 400) was noted among active men. Additional analysis of the active men group revealed that persons with CCS=0 had significantly higher energy expenditure, PA volume and better aerobic capacity as compared to other active men, but with CCS>0. CONCLUSIONS: Long-term high PA may be associated with a lower risk of developing subclinical atherosclerosis in asymptomatic middle-aged men.

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.

Gadobenate dimeglumine and gadofosveset trisodium for MR angiography of the renal arteries: Multicenter intraindividual crossover comparison.

OBJECTIVE: This prospective multicenter intraindividual crossover study was designed to compare gadobenate dimeglumine and gadofosveset trisodium at approved doses with respect to the image quality and diagnostic performance of contrast-enhanced MR angiography (CE-MRA) in the detection of clinically relevant renal artery stenosis. SUBJECTS AND METHODS: Thirty-nine subjects (17 men, 22 women; age range, 30-86 years; mean 62 +/- 13.3 [SD] years) with known or suspected renovascular disease underwent a first CE-MRA examination with 0.1 mmol/kg gadobenate dimeglumine and a second examination 3-12 days later with 0.03 mmol/kg gadofosveset. Identical T1-weighted spoiled gradient-refocused echo coronal first-pass images were acquired for 38 of the 39 patients. For 15 of the 38 patients, additional sagittal or axial images or both were acquired with gadofosveset during the steady-state phase. Thirty-four patients underwent digital subtraction angiography, which was the reference standard. Three independent blinded readers assessed source images and maximum-intensity-projection reconstructions to detect clinically relevant (> 50%) renal artery stenosis. Diagnostic performance (sensitivity, specificity, accuracy, positive and negative predictive values) was evaluated with the McNemar and Wald tests. Matched-pair determinations of diagnostic preference were evaluated with Wilcoxon's signed rank test. Reader agreement was determined with kappa analysis, and safety was assessed. RESULTS: Comparison of first-pass images revealed superior sensitivity (75.7-86.5% vs 68.4-76.3%), specificity (92.1-98.6% vs 90.5-93.9%), accuracy (88.9-96.2% vs 85.9-90.3%), positive predictive value (70.0-94.1% vs 65.0-76.3%), and negative predictive value (94.0-96.6% vs 91.7-93.9%) with gadobenate dimeglumine. Significant superiority was noted for specificity (p < or = 0.02), accuracy (p < or = 0.005), and positive predictive value (p < or = 0.018). Steady-state images showed no benefit of gadofosveset. Reader agreement was good to excellent (gadobenate dimeglumine, kappa = 0.855; gadofosveset, kappa = 0.776). Reader preference was for gadobenate dimeglumine in 11, 17, and 13 patients and for gadofosveset in five, four, and five patients. No safety concerns were noted. CONCLUSION: Better diagnostic performance and reader preference were found for gadobenate dimeglumine than gadofosveset in first-pass renal CE-MRA.