Role of cardiovascular magnetic resonance in the prognosis of patients with myocardial infarction with non-obstructive coronary arteries.

BACKGROUND: It is estimated that 5% to 10% of patients with myocardial infarction (MI) present with no obstructive coronary artery lesions. Until now, most studies have focused on acute coronary syndrome, including different clinical entities with a similar presentation encompassed under the term MINOCA (MI with non-obstructive coronary arteries). The aim of this study is to assess the prognosis of patients diagnosed with true infarction, confirmed by cardiovascular magnetic resonance (CMR), in the absence of significant coronary lesions. METHODS: Prospective multicenter registry study, including 120 consecutive patients with a CMR-confirmed MI without obstructive coronary artery lesions. The primary clinical outcome was major adverse cardiovascular events (MACE: death, non-fatal infarction, stroke, or cardiac readmission), assessed over three years. RESULTS: Seventy-six patients (63.3%) were admitted with a diagnosis of acute coronary syndrome, and 44 (36.6%) for other causes (mainly heart failure); the definitive diagnosis was established by CMR. Most patients (64.2%) were men, and the mean age was 58.8 ± 13.5 years. Patients presented with small infarcts: 83 (69.1%) showed late gadolinium enhancement (LGE) in one or two myocardial segments, mainly transmural (in 77.5% of patients) and with a preserved left ventricular ejection fraction (median 54.8%, interquartile range 37-62). The most frequent infarct location was inferolateral (n = 38, 31.7%). During follow-up, 43 patients (35.8%) experienced a MACE, including 9 (7.5%) who died. In multivariable analysis, LGE in two versus one myocardial segment doubled the risk of adverse cardiac events (hazard ratio [HR] 2.32, 95% confidence interval [CI] 0.97-5.83, p = 0.058). Involvement of three or more myocardial segments almost tripled the risk (HR 2.71, 95% CI 1.04-7.04, p = 0.040 respectively). CONCLUSIONS: Patients with true MI but without significant coronary artery lesions predominantly had small infarcts. Myocardial 3-segment LGE involvement is associated with a significantly higher risk of adverse cardiac events.

Importancia de los hallazgos de la resonancia magnética cardiaca en el diagnóstico de la miocardiopatía arritmogénica del ventrículo izquierdo / Importance of cardiac magnetic resonance findings in the diagnosis of left dominant arrythmogenic cardiomyopathy

INTRODUCCIÓN Y OBJETIVOS: Recientemente, la miocardiopatía arritmogénica del ventrículo izquierdo (MCAVI) ha sido reconocida como parte del espectro de la miocardiopatía arritmogénica. Se caracteriza por el reemplazo fibroadiposo de la pared de dicho ventrículo. Se describen las formas de presentación clínica más frecuentes, hallazgos de imagen y eventos en el seguimiento, destacando la importancia de la resonancia magnética cardiaca (RMC). MÉTODOS: Registro prospectivo de pacientes con hallazgos compatibles con MCAVI. Se realizó análisis de imagen de RMC y seguimiento clínico. El objetivo primario fue la aparición de eventos cardiovasculares adversos mayores (MACE) durante el seguimiento, definidos como muerte súbita cardiaca, arritmias ventriculares sostenidas y trasplante cardiaco. RESULTADOS: Se incluyeron 74 pacientes consecutivos (edad media 48,6 años, 50 varones [67,6%]). Las indicaciones más frecuentes para la RMC fueron dolor torácico con coronariografía normal, arritmias ventriculares y sospecha de miocardiopatías. Los principales hallazgos de RMC fueron: realce tardío meso-subepicárdico (91,9%), infiltración grasa subepicárdica (83,8%) y anomalías segmentarias de la contractilidad del ventrículo izquierdo (47,9%). En un seguimiento medio de 3,74 años, 24 pacientes (32,4%) presentaron un MACE (muerte súbita cardiaca 8,1%, arritmias ventriculares sostenidas 21,6% y trasplante cardiaco 4,1%). La presencia en RMC de realce tardío grave, predice independientemente la aparición de MACE, además del hecho de ser varón y practicar deporte. CONCLUSIONES: La RMC es una herramienta clave para diagnosticar la MCAVI. La infiltración grasa subepicárdica y el realce tardío meso-subepicárdico son hallazgos característicos. El pronóstico de esta población es pobre con una alta incidencia de muerte súbita cardiaca y arritmias ventriculares

INTRODUCTION AND OBJECTIVES: Left dominant arrhythmogenic cardiomyopathy (LDAC) has recently been recognized as falling on the spectrum of arrhythmogenic cardiomyopathy. It is characterized by fibroadipose replacement of the left ventricle. The aim of this study was to describe the most frequent forms of clinical presentation of LDAC, imaging findings, and events at follow-up, highlighting the importance of cardiac magnetic resonance (CMR). METHODS: Prospective registry of patients with findings compatible with LDAC. CMR image analysis and clinical follow-up was performed. The primary endpoint was the appearance of major adverse cardiovascular events (MACE) during follow-up, defined as sudden cardiac death, sustained ventricular arrhythmias, and heart transplant. RESULTS: We included 74 consecutive patients (mean age, 48.6 years; 50 men [67.6%]). The most frequent CMR indications were chest pain with normal coronary angiography, ventricular arrhythmias, and suspicion of cardiomyopathies. The main CMR findings were midwall and/or subepicardial pattern of late gadolinium enhancement (91.9%), fatty epicardial infiltration (83.8%), and left ventricle segmental contractility abnormalities (47.9%). At a mean follow-up of 3.74 years, 24 patients (32.4%) had a MACE (sudden cardiac death 8.1%, sustained ventricular arrhythmias 21.6%, and heart transplant 4.1%). Independent predictors for the appearance for MACE were a CMR study showing severe late gadolinium enhancement, male sex, and practicing sports. CONCLUSIONS: CMR is a key tool for diagnosing LDAC. Characteristic findings are subepicardial fatty infiltration and midwall-subepicardial late gadolinium enhancement. The prognosis of this population is poor with a high incidence of sudden cardiac death and ventricular arrhythmias

Importance of cardiac magnetic resonance findings in the diagnosis of left dominant arrythmogenic cardiomyopathy.

INTRODUCTION AND OBJECTIVES: Left dominant arrhythmogenic cardiomyopathy (LDAC) has recently been recognized as falling on the spectrum of arrhythmogenic cardiomyopathy. It is characterized by fibroadipose replacement of the left ventricle. The aim of this study was to describe the most frequent forms of clinical presentation of LDAC, imaging findings, and events at follow-up, highlighting the importance of cardiac magnetic resonance (CMR). METHODS: Prospective registry of patients with findings compatible with LDAC. CMR image analysis and clinical follow-up was performed. The primary endpoint was the appearance of major adverse cardiovascular events (MACE) during follow-up, defined as sudden cardiac death, sustained ventricular arrhythmias, and heart transplant. RESULTS: We included 74 consecutive patients (mean age, 48.6 years; 50 men [67.6%]). The most frequent CMR indications were chest pain with normal coronary angiography, ventricular arrhythmias, and suspicion of cardiomyopathies. The main CMR findings were midwall and/or subepicardial pattern of late gadolinium enhancement (91.9%), fatty epicardial infiltration (83.8%), and left ventricle segmental contractility abnormalities (47.9%). At a mean follow-up of 3.74 years, 24 patients (32.4%) had a MACE (sudden cardiac death 8.1%, sustained ventricular arrhythmias 21.6%, and heart transplant 4.1%). Independent predictors for the appearance for MACE were a CMR study showing severe late gadolinium enhancement, male sex, and practicing sports. CONCLUSIONS: CMR is a key tool for diagnosing LDAC. Characteristic findings are subepicardial fatty infiltration and midwall-subepicardial late gadolinium enhancement. The prognosis of this population is poor with a high incidence of sudden cardiac death and ventricular arrhythmias.

Pigmented villonodular synovitis diagnostic delay due to coexistence with ankylosing spondylitis / Retraso en el diagnóstico de sinovitis villonodular pigmentada por coexistencia con espondilitis anquilosante

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Effect of ischemic postconditioning on microvascular obstruction in reperfused myocardial infarction. Results of a randomized study in patients and of an experimental model in swine.

BACKGROUND: Ischemic postconditioning (PCON) appears as a potentially beneficial tool in ST-segment elevation myocardial infarction (STEMI). We evaluated the effect of PCON on microvascular obstruction (MVO) in STEMI patients and in an experimental swine model. METHODS: A prospective randomized study in patients and an experimental study in swine were carried out in two university hospitals in Spain. 101 consecutive STEMI patients were randomized to undergo primary angioplasty followed by PCON or primary angioplasty alone (non-PCON). Using late gadolinium enhancement cardiovascular magnetic resonance, infarct size and MVO were quantified (% of left ventricular mass). In swine, using an angioplasty balloon-induced anterior STEMI model, MVO was defined as the % of area at risk without thioflavin-S staining. RESULTS: In patients, PCON (n=49) in comparison with non-PCON (n=52) did not significantly reduce MVO (0 [0-1.02]% vs. 0 [0-2.1]% p=0.2) or IS (18 ± 13% vs. 21 ± 14%, p=0.2). MVO (>1 segment in the 17-segment model) occurred in 12/49 (25%) PCON and in 18/52 (35%) non-PCON patients, p=0.3. No significant differences were observed between PCON and non-PCON patients in left ventricular volumes, ejection fraction or the extent of hemorrhage. In the swine model, MVO occurred in 4/6 (67%) PCON and in 4/6 (67%) non-PCON pigs, p=0.9. The extent of MVO (10 ± 7% vs. 10 ± 8%, p=0.9) and infarct size (23 ± 14% vs. 24 ± 10%, p=0.8) was not reduced in PCON compared with non-PCON pigs. CONCLUSIONS: Ischemic postconditioning does not significantly reduce microvascular obstruction in ST-segment elevation myocardial infarction. Clinical Trial Registration http://www.clinicaltrials.gov. Unique identifier: NCT01898546.

Miocardio rescatado tras angioplastia coronaria de rescate: cuantificación mediante resonancia magnética cardiaca / Reduction in 28 days and 6 months of acute myocardial infarction Mortality From 1995 to 2005. Data from PRIAMHO I, II and MASCARA registries

Introducción y objetivos. Cuando la fibrinolisis fracasa en pacientes con infarto de miocardio con elevación del ST, está indicadad la realización de una intervención coronaria percutánea (ICP) de rescate. Sin embargo, hay pocas evidencias sobre la cantidad del miocardio en riesgo que realmente puede rescatarse tras una ICP de rescate. Métodos. Se realizó resonancia magnética cardiaca en un plazo de 6 días a 50 pacientes consecutivos. La necrosis miocárdica se definió mediante la extensión de la captación tardía de contraste; el miocardio en riesgo, mediante la extensión del edema, y la cantidad de miocardio rescatado, mediante la diferencia entre el miocardio en riesgo y la necrosis miocárdica. Finalmente, el índice de miocardio rescatado (IMR) se obtuvo a partir de la fracción área en riesgo – tamaño de infarto/área en riesgo. Resultados. La media de tiempo transcurrido entre el inicio del dolor y la administración del fármaco fibrinolítico fue de 176 ± 113min; el tiempo de lisis-ICP de rescate fue de 209±122min; el tiempo de inicio del dolor-ICP fue de 390±152min. El área en riesgo fue del 37±13% y el tamaño del infarto, del 34,5±13%. El miocardio rescatado fue un 3±4% y el IMR, 9±8. El miocardio rescatado y el IMR fueron similares en los pacientes con una arteria permeable a la llegada al laboratorio de cateterismo (Thrombolysis in Myocardial Infarction [TIMI] 3) y en los que tenían un flujo TIMI ≤ 2 (el 3,3±3,6% y 8,2±6,9 [p=0,8] en los casos de TIMI 0-2 frente al 3±3,7% y 10,8±10,9 [p=0,31] en los de TIMI 3). No se observaron diferencias significativas entre los pacientes a los que se efectuó la ICP de rescate en un plazo corto y aquellos a los se intervino tras un intervalo mayor. Conclusiones. La cantidad de miocardio rescatado tras una ICP de rescate cuantificada mediante resonancia magnética cardiaca es muy pequeña. El largo tiempo entre el inicio del dolor y la apertura de la arteria relacionada con el infarto es la causa más probable de este efecto mínimo de la ICP de rescate (AU)

Introduction and objectives. To determine whether mortality from acute myocardial infarction has reduced in Spain and the possibly related therapeutic factors. Methods. Nine thousand, nine hundred and forty-nine patients with ST-segment elevation myocardial infarction admitted to the Coronary Care Unit were identified from PRIAMHO I, II and MASCARA registries performed in 1995, 2000 and 2005, with a 6 month follow-up. Results. From 1995 to 2005 patients were increasingly more likely to have hypertension, hyperlipidemia and anterior infarction, but age of onset and the proportion of females did not increase. Twenty-eight-day mortality rates were 12.6%, 12.3% and 6% in 1995, 2000 and 2005 respectively, and 15.3%, 14.6% and 9.4% at 6 months (both P-trend <.001). Multivariate analysis was performed and the adjusted odds ratio for 28-day mortality for an infarction occuring in 2005 (compared with 1995) was 0.62 (95% confidence interval: 0.44-0.88) whereas the adjusted hazard ratio for mortality at 6 months was 0.40 (95% confidence interval: 0.24-0.67). Other variables independently associated with lower mortality at 28 days were: reperfusion therapy, and the use of anti-thrombotic treatment, beta-blockers and angiotensin-converting enzyme inhibitors. The 28-day-6-month period had an independent protective effect on the following therapies: coronary reperfusion, and prescription of antiplatelet agents, beta-blockers and lipid lowering drugs upon discharge. Conclusions. Twenty-eight-day and six-month mortality rates fell among patients with ST-elevation myocardial infarction in Spain from 1995 to 2005. The possibly related therapeutic factors were the following: more frequent reperfusion therapy and increased use of anti-thrombotic drugs, beta-blockers, angiotensin-converting enzyme inhibitors and lipid lowering drugs (AU)

[Minimum salvaged myocardium after rescue percutaneous coronary intervention: quantification by cardiac magnetic resonance]. / Miocardio rescatado tras angioplastia coronaria de rescate: cuantificación mediante resonancia magnética cardiaca.

INTRODUCTION AND OBJECTIVES: When fibrinolysis fails in patients with ST elevation myocardial infarction, they are referred for a rescue percutaneous coronary intervention (PCI). However, there is still no evidence of how much myocardium potentially at risk we can actually salvage after rescue PCI. METHODS: Fifty consecutive patients. Cardiac magnetic resonance was performed within 6 days. Myocardial necrosis was defined by the extent of abnormal late enhancement, myocardium at risk by extent of edema, and the amount of salvaged myocardium by the difference between myocardium at risk and myocardial necrosis. Finally, myocardial salvage index (MSI) resulted from the fraction (area-at-risk minus infarct-size)/area-at-risk. RESULTS: The mean time elapsed between pain onset and fibrinolitic agent administration was 176 ± 113 min; time lysis-rescue=PCI 209 ± 122 min; time pain onset-PCI = 390 ± 152 min. The area at risk was 37% ± 13% and infarct size 34.5% ± 13%. Salvaged myocardium was 3% ± 4% and MSI 9 ± 8. Salvaged myocardium and MSI were similar between patients with the artery open on arrival at the catheterization lab (Thrombolysis in Myocardial Infarction [TIMI] 3) and those with TIMI flow ≤ 2 (3.3% ± 3.6% and 8.2 ± 6.9 in TIMI 0-2 vs 3.0% ± 3.7% and 10.8 ± 10.9 in TIMI 3; P=.80 and 0.31, respectively). No significant difference was observed between patients who went through rescue PCI within a shorter time and those with longer delay times. CONCLUSIONS: The myocardial salvage after rescue PCI quantified by cardiac magnetic resonance is very small. The long delay times between pain onset and the opening of the infarct-related artery with PCI are most probably the reason for such a minimal effect of rescue PCI.

Gadolinium-enhanced cardiovascular magnetic resonance and exercise capacity in hypertrophic cardiomyopathy.

INTRODUCTION AND OBJECTIVES: Using gadolinium-enhanced cardiovascular magnetic resonance, it is possible to evaluate the presence of myocardial fibrosis in hypertrophic cardiomyopathy. Classical disease markers are weak predictors of functional disability in affected patients. Our objective was to study the relationship between the degree of myocardial fibrosis observed by cardiac magnetic resonance and exercise capacity. METHODS: We performed cardiac magnetic resonance, echocardiography, exercise testing and Holter monitoring, along with the usual clinical assessments, in 98 patients (age, 46.3+/-15.4 years, 71.4% male) referred from two specialist hypertrophic cardiomyopathy clinics. Cardiac magnetic resonance assessment included quantifying the degree of fibrosis (i.e., the percentage of the myocardium showing enhancement) 10 min after gadolinium infusion. Symptom-limited exercise testing was used to determine exercise capacity (in metabolic equivalent [MET] units). In 71 patients, the basal N-terminal probrain natriuretic peptide (NT-proBNP) level was also measured. RESULTS: Late enhancement was observed on cardiac magnetic resonance in 67 (68.4%) patients. These patients had a lower exercise capacity (8.04+/-3.56 MET vs. 10.41+/-3.57 MET; P=.003). There was an inverse correlation between the percentage of fibrosis and exercise capacity (r=-0.21; P=.044). The best predictor of exercise capacity was the logarithm of the NT-proBNP level (r=-0.5; P< .0001). Multivariate analysis confirmed that age, a history of atrial fibrillation, the basal NT-proBNP level and the presence of fibrosis were independent predictors of exercise capacity (r2 for the model=0.47). CONCLUSIONS: The observation of areas of late gadolinium enhancement on cardiac magnetic resonance was independently associated with poor exercise capacity in patients with hypertrophic cardiomyopathy.

Matrix metalloproteinases and tissue remodeling in hypertrophic cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is defined by the presence of unexplained left ventricular hypertrophy, myocyte disarray, and interstitial fibrosis. An increase in extracellular matrix produces interstitial fibrosis, by raised amounts of collagen type I/III. Regions of myocardial late gadolinium enhancement by cardiac magnetic resonance (CMR) represented increased myocardial collagen. Regarding the role of matrix metalloproteinases (MMPs) in myocardial remodeling and subsequent fibrosis, the aim of our study was to explore the relation between MMP system and myocardial late gadolinium enhancement by CMR (as expression of image-documented fibrosis) and N-terminal pro-brain natriuretic peptide (NT-proBNP) (as a marker of cardiac overload) in HCM. METHODS: We included 67 HCM patients (44 men aged 49 +/- 14 years) and were compared to 58 controls with similar age and sex. Risk factors for sudden death were recorded. A blinded CMR was performed with gadolinium. Matrix metalloproteinase 1, MMP-2, and MMP-9 plasma levels were assayed by enzyme-linked immunosorbent assay. Serum samples were used for measurement of NT-proBNP. RESULTS: In patients, >50% of MMP-1 values were below the lowest limit of detection of the technique. Raised levels of MMP-2, MMP-9, and NT-proBNP were observed in HCM patients (all P < .01). Matrix metalloproteinase 2 was associated with dyspnea (P = .049) and correlated with MMP-9 (r = 0.28, P = .025) and NT-proBNP (r = 0.39, P = .001). Matrix metalloproteinase 9 was associated with the presence of gadolinium enhancement in CMR (P = .001) and correlated with NT-proBNP (r = 0.52, P < .001). NT-proBNP was also associated with gadolinium enhancement (P = .006). Both MMP-2 and MMP-9 correlated negatively with exercise capacity (metabolic equivalent units), (r = -0.36 and r = -0.42 respectively, both P < .01). On multivariate analysis (adjusted by sudden death risk factors and echocardiographic markers), only MMP-9 was associated with fibrosis (P = .011). CONCLUSIONS: Matrix metalloproteinase 9 is independently associated with gadolinium enhancement on CMR in patients with hypertrophic cardiomyopathy, suggesting that the MMP system has an important role in cardiac remodeling and fibrosis in this condition.

Cardiorresonancia magnética con gadolinio y capacidad de esfuerzo en la miocardiopatía hipertrófica / Gadolinium-Enhanced Cardiovascular Magnetic Resonance and Exercise Capacity in Hypertrophic Cardiomyopathy

Introducción y objetivos. La cardiorresonancia magnéticacon gadolinio permite estudiar la fibrosis miocárdicaen la miocardiopatía hipertrófica. Los marcadores clásicos de la enfermedad predicen débilmente la limitación funcional de estos pacientes. Nuestro objetivo es estudiar la relación entre la fibrosis en la cardiorresonancia magnética y la capacidad de ejercicio.Métodos. Se realizó cardiorresonancia magnética, ecocardiografía, ergometría y Holter, junto con la valoración clínica habitual, a 98 pacientes procedentes de dos consultas especializadas de miocardiopatía hipertrófica (edad, 46,3 ± 15,4 años; el 71,4% varones). El estudio de cardiorresonancia magnética incluyó cuantificación de fibrosis (porcentaje de miocardio realzado) 10 min tras la inyección de gadolinio. Mediante ergometría limitada por síntomas, se determinó la capacidad de esfuerzo (MET). En 71 pacientes se obtuvieron además concentraciones plasmáticas basales de NT-proBNP.Resultados. Presentaron áreas de realce tardío en lacardiorresonancia magnética 67 (68,4%) pacientes. Estospacientes tenían peor capacidad de esfuerzo (8,04 ± 3,56frente a 10,41 ± 3,57 MET; p = 0,003). Se observó correlación negativa entre el porcentaje de fibrosis y los MET alcanzados (r = –0,21; p = 0,044). El mejor predictor de capacidad de esfuerzo fue el logNT-proBNP (r = –0,5; p <0,0001). El análisis multivariado confirmó que la edad, los antecedentes de fibrilación auricular, las concentraciones basales de NT-proBNP y la fibrosis son predictores independientes de la capacidad de esfuerzo (r2 del modelo = 0,47).Conclusiones. La presencia de áreas de realce tardíocon gadolinio en la cardiorresonancia magnética se asociade forma independiente con una peor capacidad deesfuerzo en pacientes con miocardiopatía hipertrófica

Introduction and objectives. Using gadoliniumenhancedcardiovascular magnetic resonance, it ispossible to evaluate the presence of myocardial fibrosis in hypertrophic cardiomyopathy. Classical disease markersare weak predictors of functional disability in affectedpatients. Our objective was to study the relationshipbetween the degree of myocardial fibrosis observed bycardiac magnetic resonance and exercise capacity.Methods. We performed cardiac magnetic resonance,echocardiography, exercise testing and Holter monitoring,along with the usual clinical assessments, in 98 patients(age, 46.3±15.4 years, 71.4% male) referred from twospecialist hypertrophic cardiomyopathy clinics. Cardiacmagnetic resonance assessment included quantifying thedegree of fibrosis (i.e., the percentage of the myocardium showing enhancement) 10 min after gadolinium infusion. Symptom-limited exercise testing was used to determine exercise capacity (in metabolic equivalent [MET] units). In 71 patients, the basal N-terminal probrain natriuretic peptide (NT-proBNP) level was also measured.Results. Late enhancement was observed on cardiacmagnetic resonance in 67 (68.4%) patients. Thesepatients had a lower exercise capacity (8.04±3.56 METvs. 10.41±3.57 MET; P=.003). There was an inversecorrelation between the percentage of fibrosis andexercise capacity (r=–0.21; P=.044). The best predictor of exercise capacity was the logarithm of the NT-proBNPlevel (r=–0.5; P<.0001). Multivariate analysis confirmedthat age, a history of atrial fibrillation, the basalNT-proBNP level and the presence of fibrosis wereindependent predictors of exercise capacity (r2 for themodel=0.47).Conclusions. The observation of areas of lategadolinium enhancement on cardiac magnetic resonancewas independently associated with poor exercise capacityin patients with hypertrophic cardiomyopathy

Variables associated with contrast-enhanced cardiovascular magnetic resonance in hypertrophic cardiomyopathy: clinical implications.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) shows increased myocardial collagen and disarray. Late gadolinium enhancement in cardiovascular magnetic resonance (CMR) is observed in regions of increased myocardial collagen. The extent of late gadolinium enhancement has been associated with higher prevalence of risk factors of sudden death. The aim of the present study was to describe the clinical characteristics and the presence of risk factors for sudden death in a series of patients from 2 referral centers for HCM in relation to late gadolinium enhancement in CMR. METHODS AND RESULTS: A total of 120 patients (47 +/- 16 years) were included. All patients fulfilled conventional criteria for HCM. A complete history and clinical examination were performed. Risk factors for sudden death were evaluated. A blinded CMR was performed with late gadolinium enhancement in the left ventricular short-axis orientation. NT pro B-type natriuretic protein (BNP) and C-reactive protein were determined in serum samples. A total of 83 patients (69%) showed late gadolinium enhancement. These patients had higher maximal left ventricular wall thickness (22 +/- 5 versus 17 +/- 3 mm, P < .001), showed more frequently obstruction (42% versus 16%, P = .006), nonsustained ventricular tachycardia (38% versus 8%, P = .001), worse exercise capacity (8 +/- 4 versus 10 +/- 4 METs, P = .003) and increased levels of NT BNP (656 [300-1948] versus 290 [122-948] pg/mL, P = .020). On multivariate analysis, maximal left ventricular wall thickness (P < .001) and nonsustained ventricular tachycardia (P = .011) remained associated with gadolinium-enhanced imaging. Number of risk factors for sudden death was associated with late gadolinium enhancement (OR 2.18, 95%CI 1.45-3.20, P < .001). CONCLUSIONS: Late gadolinium enhancement in CMR is a common finding in HCM. Increased maximal left ventricular wall thickness and nonsustained ventricular tachycardia are associated with late gadolinium enhancement. Associations with risk factors for sudden death and functional status are observed.

Valor de la coronariografía por resonancia magnética en el diagnóstico del origen anómalo de las arterias coronarias. A propósito de un caso / The value of magnetic resonance coronariography in the diagnosis of anomalous origin of the coronary arteries. A case report

La incidencia de anomalías congénitas de las arterias coronarias oscila, en las distintas series coronariográficas publicadas, entre el 0,3 y el 1,3%. Inicialmente, estas anomalías se consideraron simples hallazgos, sin que se les asignara ninguna significación clínica. Esta creencia se deshizo posteriormente al describirse casos de síncope, angina, infarto agudo de miocardio y muerte súbita asociados a su presencia. Se conoce que las complicaciones clínicas pueden estar en relación con el trayecto que sigue la arteria coronaria anómala. Presentamos un caso de anomalía congénita de la arteria coronaria izquierda con nacimiento en el seno coronario derecho, en una mujer de 74 años con angina inestable prolongada, en el que la resonancia magnética demostró ser definitiva en la determinación del trayecto exacto de dicha coronaria anómala

The incidence of congenital anomalies of the coronary arteries reported in different series ranges from 0.3 to 1.3%. These anomalies were initially considered to be findings with no clinical significance. Later reports of syncope, angina, acute myocardial infarction and sudden death related to their presence changed this belief. Clinical complications are known to be related to the course of the anomalous coronary artery. We present a case of a congenital anomaly of the left coronary artery arising from the right coronary sinus in a 74-year-old woman with long-standing unstable angina in which magnetic resonance imaging provided the definitive determination of the exact course of this coronary anomaly