Comparative analysis of late gadolinium enhancement assessment techniques for monitoring fibrotic changes in myocarditis follow-up.

OBJECTIVES: To compare the repeatability and interrelation of various late gadolinium enhancement (LGE) assessment techniques for monitoring fibrotic changes in myocarditis follow-up. MATERIALS AND METHODS: LGE extent change between baseline and 3-month cardiovascular magnetic resonance (CMR) was compared in patients with acute myocarditis using the full width at half maximum (FWHM), gray-scale thresholds at 5 and 6 standard deviations (SD5 and SD6), visual assessment with threshold (VAT) and full manual (FM) techniques. In addition, visual presence score (VPS), visual transmurality score (VTS), and a simplified visual change score (VCS) were assessed. Intraclass-correlation (ICC) was used to evaluate repeatability, and methods were compared using Spearman's correlation. RESULTS: Forty-seven patients (38 male, median age: 27 [IQR: 21; 38] years) were included. LGE extent change differed among quantitative techniques (p < 0.01), with variability in the proportion of patients showing LGE change during follow-up (FWHM: 62%, SD5: 74%, SD6: 66%, VAT: 43%, FM: 60%, VPS: 53%, VTS: 77%, VCS: 89%). Repeatability was highest with FWHM (ICC: 0.97) and lowest with SD5 (ICC: 0.89). Semiquantitative scoring had slightly lower values (VPS ICC: 0.81; VTS ICC: 0.71). VCS repeatability was excellent (ICC: 0.93). VPS and VTS correlated with quantitative techniques, while VCS was positively associated with VPS, VTS, VAT, and FM, but not with FWHM, SD5, and SD6. CONCLUSION: FWHM offers the least observer-dependent LGE follow-up after myocarditis. VPS, VTS, and VCS are practical alternatives, showing reliable correlations with quantitative methods. Classification of patients exhibiting either stable or changing LGE relies on the assessment technique. CLINICAL RELEVANCE STATEMENT: This study shows that LGE monitoring in myocarditis is technique-dependent; the FWHM method yields the most consistent fibrotic tracking results, with scoring-based techniques as reliable alternatives. KEY POINTS: Recognition of fibrotic changes during myocarditis follow-up is significantly influenced by the choice of the quantification technique employed. The FWHM technique ensures highly repeatable tracking of myocarditis-related LGE changes. Segment-based visual scoring and the simplified visual change score offer practical, reproducible alternatives in resource-limited settings.

Clinical and CMR characteristics associated with cardiac events in patients with Fabry disease.

BACKGROUND: The assessment of late gadolinium enhancement (LGE) and left ventricular hypertrophy (LVH) by cardiac magnetic resonance (CMR) as diagnostic and prognostic maker in Fabry disease is advancing. We aimed to investigate the impact of clinical characteristics and CMR findings on cardiac outcome in patients with FD. METHODS: In this study 55 patients with genetically confirmed FD and available CMR imaging were included. The primary endpoint was defined as a composite of cardiac events including cardiac death, new occurrence of atrial fibrillation, heart failure, ventricular tachycardia and bradycardia requiring device insertion. RESULTS: During a median follow-up of 4.9 years (IQR 3.7-5.9), 9 patients (16.3%) reached the primary cardiac end point. The global amount of LGE was associated with an increased risk for primary endpoint in the univariate analysis (HR 1.4 per 10% increase in LGE, p = 0.002). However maximal wall thickness (MWT) was the sole independent predictor of the primary endpoint in a stepwise logistic regression model (HR 9.8 per mm increase in MWT, p < 0.0001). Kaplan-Meier analysis revealed significant difference in event free survival rate between patients with and without LVH (Long-rank p = 0.006) and in patients with and without LGE (Long-rank p < 0.001). Patients without LVH and LGE were free of adverse cardiac events. CONCLUSION: LVH and LGE detected by CMR were associated with adverse cardiac events in FD. In particular maximal wall thickness can be useful in cardiac risk stratification of FD patients.

Association between ECG parameters and late gadolinium enhancement along the course of myocarditis.

PURPOSE: Numerous electrocardiogram (ECG) abnormalities and late gadolinium enhancement (LGE) in cardiac magnetic resonance imaging (CMR) have been related to poor prognosis in acute myocarditis. We evaluated whether ECG parameters are associated with the distribution and dynamic of LGE along the course of myocarditis. METHODS: Fifty-one patients with CMR confirmed acute myocarditis were included who underwent CMR with LGE and 12-lead ECG at baseline and 3-month follow-up at our institution. The association between the presence, regional distribution and change of ECG parameters and LGE was investigated using linear regression analysis. LGE was quantified as visual presence score (VPS) and visual transmurality score (VTS). RESULTS: Among many ECG parameters only > 1 mm ST-elevation (STE) was associated with VPS and VTS at baseline (ß = 3.08 [95%CI: 1.75; 4.41], p = < 0.001 and ß = 5.40 [95%CI: 1.92; 8.88], p = 0.004; respectively). STE was most frequent in lateral and inferior ECG-leads (48% and 31%) and it was associated with VPS and VTS in these localizations (p < 0.05 all), however no association between anterior-septal STE and LGE could be confirmed. At follow-up the regression of STE was associated with the regression of VPS and VTS in univariate analysis (ß=-1.49 [95%CI: -2.41; -0.57], p = 0.003 and ß=-4.87 [95%CI: -7.18; -2.56], p = 0.001, respectively), which remained significant for VTS using a multivariate model (ß=-2.39 [95%CI: -3.32; -0.47], p = 0.019). CONCLUSION: Although we demonstrated some promising associations between STE and LGE, the usability of ECG to estimate the territorial involvement and dynamical changes of LGE along the course of myocarditis is generally limited and cardiac magnetic resonance should be considered for this purpose.

Parametric mapping CMR for the measurement of inflammatory reactions of the pericardium.

OBJECTIVES: Although cardiovascular magnetic resonance (CMR) is increasingly used to diagnose pericardial inflammation, imaging can still be challenging using conventional CMR techniques. Parametric mapping (T1/T2 mapping) techniques have emerged as novel methods to quantify focal and global changes of the myocardium without contrast agent. The aim of the present study was to implement parametric mapping to facilitate diagnostic decision-making in pericardial inflammation. METHODS: Twenty patients with pericardial inflammation underwent CMR (1.5T system) including T1-weighted/T2-weighted imaging, T1/T2 mapping and late gadolinium enhancement. T1/T2 mapping was performed in end-diastole covering three short-axis slices. Diagnosis of pericardial inflammation was made according to recent guidelines. T1/T2 measurements were pursued by manually drawing regions of interest (ROIs) in the thickened, diseased pericardium carefully avoiding contamination by other cardiac structures. Parametric values were correlated to further markers of pericardial inflammation, such as pericardial thickening and inflammatory parameters. RESULTS: On average, the pericardium displayed a thickness of 4.8±1.0 mm. Mean T1 value was 1363.0±227.1 ms and T2 value was 123.3±52.6 ms, which were above patient's myocardial values (myocardial T1: 998.7±81.0 ms, p<0.001, median 1014.46 ms; T2: 68.0±28.9 m,p<0.001) and the values of a group of four patients with chronic pericarditis (T1: 953.0±16.7 ms; T2: 63.2±10.1 ms). T1 and T2 showed a correlation to the extent of the thickened pericardium (R=0.64, p=0.002 for T1, R=0.72, p=0.005 for T2). There was no correlation of pericardial T1/T2 to blood markers of inflammation, myocardial injury (C reactive protein, troponin, creatine kinase) or further CMR parameters. CONCLUSIONS: In patients with pericardial inflammation, parametric mapping showed elevated T1 and T2 values. Parametric mapping may help to facilitate diagnosis of pericardial inflammation if conventional parameters such as pericardial hyperintensity in T1-weighted or T2-weighted imaging or contrast agent uptake are heterogeneous.

History of Heart Failure in Patients Hospitalized Due to COVID-19: Relevant Factor of In-Hospital Complications and All-Cause Mortality up to Six Months.

BACKGROUND: Patients with heart failure (HF) are at high risk of unfavorable courses of COVID-19. The aim of this study was to evaluate characteristics and outcomes of COVID-19 patients with HF. METHODS: Data of patients hospitalized in a tertiary hospital in Poland between March 2020 and May 2021 with laboratory-confirmed COVID-19 were analyzed. The study population was divided into a HF group (patients with a history of HF) and a non-HF group. RESULTS: Out of 2184 patients (65 ± 13 years old, 50% male), 12% had a history of HF. Patients from the HF group were older, more often males, had more comorbidities, more often dyspnea, pulmonary and peripheral congestion, inflammation, and end-organ damage biomarkers. HF patients had longer and more complicated hospital stay, with more frequent acute HF development as compared with non-HF. They had significantly higher mortality assessed in hospital (35% vs. 12%) at three (53% vs. 22%) and six months (72% vs. 47%). Of 76 (4%) patients who developed acute HF, 71% died during hospitalization, 79% at three, and 87% at six months. CONCLUSIONS: The history of HF identifies patients with COVID-19 who are at high risk of in-hospital complications and mortality up to six months of follow-up.

A Novel Diagnostic Score Integrating Atrial Dimensions to Differentiate between the Athlete's Heart and Arrhythmogenic Right Ventricular Cardiomyopathy.

OBJECTIVE: The 2010 Task Force Criteria (TFC) have not been tested to differentiate ARVC from the athlete's heart. Moreover, some criteria are not available (myocardial biopsy, genetic testing, morphology of ventricular tachycardia) or subject to interobserver variability (right ventricular regional wall motion abnormalities) in clinical practice. We hypothesized that atrial dimensions are useful and robust to differentiate between both entities and proposed a new diagnostic score based upon readily available parameters including echocardiographic atrial dimensions. METHODS: In this observational study, 21 patients with definite ARVC were matched for age, gender and body mass index to 42 athletes. Based on ROC analysis, the following parameters were included in the score: indexed right/left atrial volumes ratio (RAVI/LAVI ratio), NT-proBNP, RVOT measurements (PLAX and PSAX BSA-corrected), tricuspid annular motion (TAM), precordial TWI and depolarization abnormalities according to TFC. RESULTS: ARVC patients had a higher RAVI/LAVI ratio (1.76 ± 1.5 vs. 0.87 ± 0.2, p < 0.001), lower right ventricular function (fac: 29 ± 10.1 vs. 42.2 ± 5%, p < 0.001; TAM: 19.8 ± 5.4 vs. 23.8 ± 3.8 mm, p = 0.001) and higher serum NT-proBNP levels (345 ± 612 vs. 48 ± 57 ng/L, p < 0.001). Our score showed a good performance, which is comparable to the 2010 TFC using those parameters, which are available in routine clinical practice (AUC93%, p < 0.001 (95%CI 0.874-0.995) vs. AUC97%, p < 0.001 (95%CI 0.93-1.00). A score of 6/12 points yielded a specificity of 91% and an improved sensitivity of 67% for ARVC diagnosis as compared to a sensitivity of 41% for the abovementioned readily available 2010 TFC. CONCLUSIONS: ARVC patients present with significantly larger RA compared to athletes, resulting in a greater RAVI/LAVI ratio. Our novel diagnostic score includes readily available clinical parameters and has a high diagnostic accuracy to differentiate between ARVC and the athlete's heart.

Heart failure in COVID-19: the multicentre, multinational PCHF-COVICAV registry.

AIMS: We assessed the outcome of hospitalized coronavirus disease 2019 (COVID-19) patients with heart failure (HF) compared with patients with other cardiovascular disease and/or risk factors (arterial hypertension, diabetes, or dyslipidaemia). We further wanted to determine the incidence of HF events and its consequences in these patient populations. METHODS AND RESULTS: International retrospective Postgraduate Course in Heart Failure registry for patients hospitalized with COVID-19 and CArdioVascular disease and/or risk factors (arterial hypertension, diabetes, or dyslipidaemia) was performed in 28 centres from 15 countries (PCHF-COVICAV). The primary endpoint was in-hospital mortality. Of 1974 patients hospitalized with COVID-19, 1282 had cardiovascular disease and/or risk factors (median age: 72 [interquartile range: 62-81] years, 58% male), with HF being present in 256 [20%] patients. Overall in-hospital mortality was 25% (n = 323/1282 deaths). In-hospital mortality was higher in patients with a history of HF (36%, n = 92) compared with non-HF patients (23%, n = 231, odds ratio [OR] 1.93 [95% confidence interval: 1.44-2.59], P < 0.001). After adjusting, HF remained associated with in-hospital mortality (OR 1.45 [95% confidence interval: 1.01-2.06], P = 0.041). Importantly, 186 of 1282 [15%] patients had an acute HF event during hospitalization (76 [40%] with de novo HF), which was associated with higher in-hospital mortality (89 [48%] vs. 220 [23%]) than in patients without HF event (OR 3.10 [2.24-4.29], P < 0.001). CONCLUSIONS: Hospitalized COVID-19 patients with HF are at increased risk for in-hospital death. In-hospital worsening of HF or acute HF de novo are common and associated with a further increase in in-hospital mortality.

10 year trends in hospitalization rates due to heart failure and related in-hospital mortality in Poland (2010-2019).

AIMS: Heart failure (HF) remains a major public health challenge worldwide. Contemporary epidemiological data on HF hospitalization rates and related in-hospital mortality are scarce also in Poland. The aim of the study was to determine the trends in hospitalization rates due to HF and related in-hospital mortality in Poland in the recent decade. METHODS AND RESULTS: Data on HF hospitalizations and in-hospital mortality in patients aged >17 years in Poland between 2010 and 2019 were obtained from the central database of the Polish National Health Fund. Hospitalizations with either primary or secondary diagnosis of HF were identified using the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes (I50, I42, J81 with extensions, and R57.0). There were 4 259 698 HF hospitalizations and 608 577 in-hospital deaths (14% in-hospital mortality) reported during 2010-2019 in Poland. During this period, there was a steady increase in the number of HF hospitalizations per 1000 inhabitants in subsequent years, being more pronounced in men than in women (in 2019: 16 and 13 HF hospitalizations per 1000 inhabitants in men and women, respectively). The relative risk of HF hospitalization was higher in men than in women, and this gender-related difference steadily increased from 9% in 2010 to 25% in 2019. During 2010-2019, there was an increase in the number of HF hospitalizations per 1000 inhabitants in subsequent age groups, with a trend being more pronounced in men than in women (129 and 99 HF hospitalizations per 1000 inhabitants in men and women aged ≥80 years, respectively). During this period, there was a slight increase in in-hospital mortality during HF hospitalization in subsequent years, being more pronounced in women than in men (in 2019: 16% and 14% of in-hospital mortality in women and men, respectively). The relative risk of in-hospital mortality during HF hospitalization was higher in women than in men, and this gender-related difference steadily increased from 8% in 2010 to 18% in 2019. During this period, in-hospital mortality during HF hospitalization was ~12% for women and men aged 18-29 years, whereas the highest values of in-hospital mortality reached ~19% for patients aged ≥80 years. CONCLUSIONS: We have observed steady growing trends in HF hospitalization rates and related in-hospital mortality in Poland over the last decade. Both age and gender have differentiated the reported epidemiological patterns.

Cardiac magnetic resonance imaging to detect ischemia in chronic coronary syndromes: state of the art.

The new 2019 European Society of Cardiology guidelines for the diagnosis and management of chronic coronary syndromes emphasize the role of noninvasive functional imaging of myocardial ischemia in diagnosing coronary artery disease to guide decision making regarding revascularization. Cardiac magnetic resonance imaging (CMR) stands out relative to other imaging modalities given its high safety profile, absence of ionizing radiation, and its versatility in encoding various image contrasts. It also allows an assessment of myocardial function, ischemia, and viability as well as permits tissue characterization including detection of edema in a single examination. In recent years, a number of meta­analyses and studies considering the role of CMR for detecting ischemia have been published. The recent multicenter randomized MR­INFORM trial has demonstrated the clinical utility of CMR in patients with stable angina and cardiovascular risk factors. This landmark study has proved that a perfusion CMR­based strategy leads to a lower number of revascularizations while being noninferior to an invasive coronary angiography with fractional flow reserve-guided therapy in terms of major adverse cardiac events at 1 year. In light of recent and future technical improvements, CMR will become increasingly important in the assessment of myocardial ischemia in patients with chronic coronary syndromes.

Multi-organ dysfunction/injury on admission identifies acute heart failure patients at high risk of poor outcome.

BACKGROUND: Clinical consequences of an interplay between dysfunction/injury of different end-organs in acute heart failure (AHF) remain unknown. METHODS AND RESULTS: In 284 consecutive AHF patients, end-organ dysfunction/injury was defined as cardiac [troponin I level above the upper reference limit (URL, > 0.056 ng/mL)], kidney (estimated glomerular filtration rate < 60 mL/min/1.73 m2 ), and liver [at least one of the following: aspartate transaminase (AST)/alanine transaminase (ALT) > 3 times the URL (> 114 IU/L and > 105 IU/L for AST and ALT, respectively), bilirubin above the URL (> 1.3 mg/mL), albumin below the lower reference limit (< 3.5 mg/dL)]. The primary endpoints were early (within first 48 h) in-hospital worsening of heart failure and 1-year all-cause mortality. On admission, cardiac, kidney, liver dysfunction/injury were present in 38%, 50%, and 54% of patients, respectively. Patients were classified as having 0, 1, 2, or 3 organ injury/dysfunction (17%, 36%, 35%, and 12% of patients, respectively). Baseline clinical characteristics and co-morbidity profile were similar across groups. Patients with three organ dysfunction/injury had the worst 1-year survival rate [46%; hazard ratio (HR) with 95% confidence interval (CI) vs. patients without organ dysfunction: 6.75 (2.52-18.13), those with two (67%; HR 3.54, 95% CI 1.38-9.08), one (84%; HR 1.58, 95% CI 0.58-4.30), or no organ dysfunction/injury (90%); P < 0.01]. Worsening of heart failure was more frequent in patients with three and two vs. those with one or no organ dysfunction/injury (37% vs. 38% vs. 23% vs. 21%, P < 0.05). CONCLUSIONS: In patients with AHF, dysfunction/injury of > 1 end-organ dysfunction/injury identifies patients at the highest risk of poor outcomes.

Clinical profile and management of outpatients with non-ischemic and non-hypertensive systolic heart failure: Analysis of the Polish DATA-HELP registry.

BACKGROUND: Although coronary artery disease and arterial hypertension are the most common etiologies underlying heart failure (HF), there are still many patients present with non-ischemic and non-hypertensive HF whose management remains very challenging. In this research study the clinical profile and applied treatment of patients with HF without coronary artery disease or hypertension versus patients with known etiology of HF (ischemic/hypertensive) were compared. METHODS: Clinical data about 5563 patients with stable systolic HF were obtained from prospective multicenter DATA-HELP registry performed between October and December 2009 in ambulatory clinics in Poland, in which 500 cardiologists and 290 general practitioners participated. RESULTS: Heart failure of non-ischemic and non-hypertensive etiology which affected 10% of all patients and was particularly frequent in younger patients, both in women: < 50 years old 42%; 50-65 years old 12%; > 65 years old 7%; and men: < 50 years old 47%; 50-65 years old 10%; > 65 years old 5%; p < 0.0001. Patients with non-ischemic and non-hypertensive HF were characterized by younger age, fewer co-morbidities, shorter duration of HF and, surprisingly, more advanced HF. Patients in this group were less likely to have received life-prolonging treatment in HF recommended by European Society of Cardiology (ESC) and more often required symptomatic management. Similarly, they were more likely to have implanted CRT-D and ICD. CONCLUSIONS: Heart failure of non-ischemic and non-hypertensive origin affects particularly young patients. These patients, despite suffering from more advanced HF are not optimally managed according to ESC guidelines.