Treatment of Advanced Heart Failure-Focus on Transplantation and Durable Mechanical Circulatory Support: What Does the Future Hold?

Heart transplantation (HTx) is the treatment of choice in patients with late-stage advanced heart failure (Advanced HF). Survival rates 1, 5, and 10 years after transplantation are 87%, 77%, and 57%, respectively, and the average life expectancy is 9.16 years. However, because of the donor organ shortage, waiting times often exceed life expectancy, resulting in a waiting list mortality of around 20%. This review aims to provide an overview of current standard, recent advances, and future developments in the treatment of Advanced HF with a focus on long-term mechanical circulatory support and HTx.

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.

Myocardial blood flow and cardiac sympathetic innervation in young adults late after arterial switch operation for transposition of the great arteries.

BACKGROUND: The arterial switch operation (ASO) for repair of transposition of the great arteries (TGA) requires transection of the great arterial trunks and re-implantation of the coronary arteries into the neoaortic root resulting in cardiac sympathetic denervation which may affect myocardial blood flow (MBF) regulation. The aims of the present study were to evaluate sympathetic (re-)innervation in young adults after ASO and its impact on MBF. METHODS: Twelve patients (age 22.5 ±â€¯2.6 years) after ASO for TGA in the neonatal period and ten healthy controls (age 22.0 ±â€¯1.7 years) were included. Positron emission tomography (PET) was used for measuring cardiac sympathetic innervation with [11C]meta-hydroxyephedrine (mHED) and MBF with [15O]H2O PET at rest, during adenosine stimulation, and during sympathetic stimulation with cold pressor test. Cold pressor-induced MBF response capacity was calculated as maximal global MBF over peak rate-pressure product multiplied by 10'000. RESULTS: Global [11C]mHED uptake was significantly lower in patients compared to controls (7.0 ±â€¯2.3 versus 11.8 ±â€¯2.1%/min, p < 0.001). Global MBF was lower in patients compared to controls at rest and during adenosine-induced hyperemia (0.66 ±â€¯0.08 versus 0.82 ±â€¯0.15 ml/min/g, p = 0.005; 2.23 ±â€¯1.19 versus 3.36 ±â€¯1.04 ml/min/g, p = 0.030, respectively). Interestingly, MBF during cold pressor test did not differ between patients and controls (0.99 ±â€¯0.20 versus 1.07 ±â€¯0.16 ml/min/g, p = 0.330). However, cold pressor-induced MBF response capacity was significantly lower for patients as compared to controls (1.09 ±â€¯0.35 versus 1.44 ±â€¯0.39 ml/g/10,000 mmHg, p = 0.040). CONCLUSIONS: With only partial sympathetic re-innervation of the coronary arteries, maximal dilator capacity of the coronary microvasculature and cold pressor-induced MBF response capacity remain substantially impaired in young adults after ASO compared to healthy controls.

Right Ventricular Failure: Pathophysiology, Diagnosis and Treatment.

The prognostic significance of the right ventricle (RV) has recently been recognised in several conditions, primarily those involving the left ventricle, the lungs and their vascular bed, or the right-sided chambers. Recent advances in imaging techniques have created new opportunities to study RV anatomy, physiology and pathophysiology, and contemporary research efforts have opened the doors to new treatment possibilities. Nevertheless, the treatment of RV failure remains challenging. Optimal management should consider the anatomical and physiological particularities of the RV and include appropriate imaging techniques to understand the underlying pathophysiological mechanisms. Treatment should include rapid optimisation of volume status, restoration of perfusion pressure and improvement of myocardial contractility and rhythm, and, in case of refractory RV failure, mechanical circulatory support.

Hybrid SPECT Perfusion Imaging and Coronary CT Angiography: Long-term Prognostic Value for Cardiovascular Outcomes.

Purpose To determine the value of cardiac hybrid imaging, performed by combining SPECT myocardial perfusion imaging (MPI) with coronary CT angiography, as a long-term predictor for major adverse cardiac events (MACEs) (death, myocardial infarction [MI], unstable angina requiring hospitalization, coronary revascularization). Materials and Methods For this retrospective single-center study, 428 patients referred between May 2005 and December 2008 were classified according to hybrid imaging findings into the following groups: (a) those with stenosis of 50% or greater (at coronary CT angiography) with ischemia (at SPECT) in subtended territory (matched), (b) those with coronary CT angiography and/or SPECT findings in unrelated territories (unmatched), and (c) those with normal findings at coronary CT angiography and SPECT. End points were all-cause death or MI ("hard events") and a composite of MACEs. The Kaplan-Meier method was used to identify survival free of MACEs, and Cox proportional hazard regression analysis was used to determine independent predictors for MACE. Results During a median follow-up of 6.8 years, a total of 160 MACEs, including 45 deaths, were observed in the final study population (mean age, 62 years ± 11 [standard deviation]; 132 women). The annual hard event rate was more than fivefold higher for patients with matched findings (n = 46 [7.0%]) and was threefold higher for patients with unmatched findings (n = 113 [3.7%]) compared with that for patients with normal findings (1.2%; n = 216 [1.2%]; P < .001). The MACE rates were 21.8%, 9.0%, and 2.4% for matched, unmatched, and normal findings, respectively. A matched finding was an independent predictor for MACE and hard events. Conclusion In patients evaluated for coronary artery disease, cardiac hybrid imaging is an excellent long-term predictor of adverse cardiac events. A matched hybrid finding is associated with a high annual cardiac event rate. © RSNA, 2018.

Head-to-head comparison of adaptive statistical and model-based iterative reconstruction algorithms for submillisievert coronary CT angiography.

Aims: Iterative reconstruction (IR) algorithms allow for a significant reduction in radiation dose of coronary computed tomography angiography (CCTA). We performed a head-to-head comparison of adaptive statistical IR (ASiR) and model-based IR (MBIR) algorithms to assess their impact on quantitative image parameters and diagnostic accuracy for submillisievert CCTA. Methods and results: CCTA datasets of 91 patients were reconstructed using filtered back projection (FBP), increasing contributions of ASiR (20, 40, 60, 80, and 100%), and MBIR. Signal and noise were measured in the aortic root to calculate signal-to-noise ratio (SNR). In a subgroup of 36 patients, diagnostic accuracy of ASiR 40%, ASiR 100%, and MBIR for diagnosis of coronary artery disease (CAD) was compared with invasive coronary angiography. Median radiation dose was 0.21 mSv for CCTA. While increasing levels of ASiR gradually reduced image noise compared with FBP (up to - 48%, P < 0.001), MBIR provided largest noise reduction (-79% compared with FBP) outperforming ASiR (-59% compared with ASiR 100%; P < 0.001). Increased noise and lower SNR with ASiR 40% and ASiR 100% resulted in substantially lower diagnostic accuracy to detect CAD as diagnosed by invasive coronary angiography compared with MBIR: sensitivity and specificity were 100 and 37%, 100 and 57%, and 100 and 74% for ASiR 40%, ASiR 100%, and MBIR, respectively. Conclusion: MBIR offers substantial noise reduction with increased SNR, paving the way for implementation of submillisievert CCTA protocols in clinical routine. In contrast, inferior noise reduction by ASiR negatively affects diagnostic accuracy of submillisievert CCTA for CAD detection.

Long-term outcome prediction by functional parameters derived from coronary computed tomography angiography.

BACKGROUND: Estimation of hemodynamic relevance of a coronary stenosis from coronary computed angiography (CCTA) has raised substantial interest. Recently, the corrected coronary opacification (CCO) decrease and the transluminal attenuation gradient (TAG) have been suggested as faster alternatives to the FFRCT. The aim of the study was to evaluate whether the diagnostic accuracy of CCO decrease and TAG translates into an added prognostic value in patients evaluated for coronary artery disease (CAD). METHODS: This retrospective study consists of 162 consecutive patients referred for evaluation of known or suspected CAD by CCTA. CCO decrease was defined as difference of mean luminal coronary attenuation normalized to aorta attenuation proximal-distal of a stenosis. To calculate TAG, mean attenuation was measured at 5-mm intervals from the ostium to a distal segment with a minimal cross-sectional area of 2.0mm2. Death, myocardial infarction, unstable angina requiring hospitalization, and coronary revascularization were defined as major adverse cardiac events (MACE). Multivariate analysis included covariates age, sex, ≥3 cardiovascular risk factors and stenosis severity. RESULTS: Follow-up was completed in 154 patients, CAD was found in 72. During median follow-up of 6.1years (interquartile range, 5.8-6.9years), 55 patients experienced a MACE. Among CAD patients, the presence of an abnormal CCO decrease (p<0.05) but not TAG (p=0.894) was associated with a worse MACE-free survival. In multivariate analysis, CCO decrease was an independent predictor of MACE (HR, 2.27; 95% CI, 1.14-4.52; p=0.02) while TAG was not predictive (p=0.895). CONCLUSION: In CAD patients, CCO decrease adds long-term prognostic value over clinical characteristics and stenosis severity while TAG does not.

Long-term prognostic performance of low-dose coronary computed tomography angiography with prospective electrocardiogram triggering.

OBJECTIVES: To assess long-term prognosis after low-dose 64-slice coronary computed tomography angiography (CCTA) using prospective electrocardiogram-triggering. METHODS: We included 434 consecutive patients with suspected or known coronary artery disease referred for low-dose CCTA. Patients were classified as normal, with non-obstructive or obstructive lesions, or previously revascularized. Coronary artery calcium score (CACS) was assessed in 223 patients. Follow-up was obtained regarding major adverse cardiac events (MACE): cardiac death, myocardial infarction and elective revascularization. We performed Kaplan-Meier analysis and Cox regressions. RESULTS: Mean effective radiation dose was 1.7 ± 0.6 mSv. At baseline, 38% of patients had normal arteries, 21% non-obstructive lesions, 32% obstructive stenosis and 8% were revascularized. Twenty-nine patients (7%) were lost to follow-up. After a median follow-up of 6.1 ± 0.6 years, MACE occurred in 0% of patients with normal arteries, 6% with non-obstructive lesions, 30% with obstructive stenosis and 39% of those revascularized. MACE occurrence increased with increasing CACS (P < 0.001), but 4% of patients with CACS = 0 experienced MACE. Multivariate Cox regression identified obstructive stenosis, lesion burden in CCTA and CACS as independent MACE predictors (P ≤ 0.001). CONCLUSION: Low-dose CCTA with prospective electrocardiogram-triggering has an excellent long-term prognostic performance with a warranty period >6 years for patients with normal coronary arteries. KEY POINTS: • Coronary CT angiography (CCTA) has an excellent long-term prognostic performance. • CCTA can accurately stratify cardiac risk according to coronary lesion severity. • A normal CCTA predicts freedom from cardiac events for >6 years. • Patients with a coronary calcium score of 0 may experience cardiac events. • CCTA allows for reclassification of cardiac risk compared with ESC SCORE.

A low-dose and an ultra-low-dose contrast agent protocol for coronary CT angiography in a clinical setting: quantitative and qualitative comparison to a standard dose protocol.

OBJECTIVE: To evaluate the impact of a low-dose (LD) and an ultra-LD (ULD) contrast protocol for coronary CT angiography on qualitative and quantitative image parameters in a clinical setting. METHODS: We scanned 120 consecutive patients with a 256-slice CT scanner applying a LD (60 patients, 35-55 ml) or ULD (60 patients, 25-45 ml) contrast protocol adapted to the body mass index. Visually assessed image quality and attenuation measured in each coronary segment were retrospectively compared in 20 consecutive patients scanned with a normal-dose (ND, 40-105 ml) contrast protocol. RESULTS: Visually assessed image quality did not differ significantly among protocols. By contrast, attenuation obtained from the ULD protocol (median contrast volume 35 ml) differed significantly from the LD (median 45 ml) and ND (median 70 ml) protocols in the coronary segments (316 ± 52 vs 363 ± 60 and 359 ± 52 HU, p < 0.001). Attenuation did not differ significantly between the LD and ND protocol. The proportion of patients with inadequate coronary vessel attenuation was significantly higher (p < 0.001) in the ULD protocol (37%) than in the ND (5%) and LD (10%) protocols but did not differ significantly between the ND and LD protocols. CONCLUSION: In a clinical setting, a LD contrast protocol with a median volume of 45 ml is feasible for the latest generation 256-slice coronary CT angiography as it yields attenuation comparable to a ND protocol. By contrast, the implementation of an ULD protocol remains challenging. Advances in knowledge: Although not perceived by the naked eye, an ULD contrast protocol in a clinical setting yields attenuation below a threshold for diagnostic image quality.

Outcome in middle-aged individuals with anomalous origin of the coronary artery from the opposite sinus: a matched cohort study.

AIMS: Anomalous origin of a coronary artery from the opposite sinus (ACAOS) has been associated with adverse cardiac events in the young. It remains unknown whether this holds true for middle-aged patients with uncorrected ACAOS as well. We assessed the outcome in middle-aged patients with newly diagnosed ACAOS by coronary computed tomography angiography (CCTA) compared with a matched cohort. METHODS AND RESULTS: We retrospectively identified 68 consecutive patients with ACAOS documented by CCTA. ACAOS with a course of the anomalous vessel between the aorta and pulmonary artery were classified as interarterial course (IAC). Each patient with ACAOS was matched to two controls without ACAOS. Major adverse cardiac events (i.e. myocardial infarction, revascularization and cardiac death) were recorded for all patients and controls. Two (3%) patients were lost to follow-up. Thus, 66 patients with ACAOS were included in the final analysis and matched with 132 controls. Mean age of patients was 56 ± 11 years, 73% were male and the mean follow-up was 49 months. Forty (65%) patients were classified as having ACAOS with IAC. The annual event rate of ACAOS vs. controls was 4.9 and 4.8%, the hazard ratio (HR) 0.94 (0.39-2.28, P = 0.89). The annual event rate of ACAOS with IAC compared with their matched controls was 5.2 and 4.3%, and the HR 1.01 (95% CI 0.39-2.58, P = 0.99). CONCLUSIONS: In middle-aged individuals with newly diagnosed ACAOS mid-term outcome is not statistically different to a matched control cohort without coronary artery anomalies, regardless of whether ACAOS with or without IAC variants are present.

Real-time respiratory triggered SPECT myocardial perfusion imaging using CZT technology: impact of respiratory phase matching between SPECT and low-dose CT for attenuation correction.

AIMS: To assess the impact of respiratory phase matching between single-photon-emission computed tomography myocardial perfusion imaging (SPECT-MPI) and low-dose computed tomography (CT) for attenuation correction (AC). METHODS AND RESULTS: Forty patients underwent 1-day 99mTc-tetrofosmin pharmacological stress/rest SPECT-MPI using a cadmium-zinc-telluride gamma camera. Low-dose CT for AC was performed at deep-inspiration breath-hold. SPECT-MPI was acquired once with free-breathing (FB) and repeated at deep-inspiration breath-hold (BH) to match the respiratory phase of AC. From these acquisitions we reconstructed four data sets: free-breathing SPECT-MPI without AC (non-corrected; FB-NC), breath-hold SPECT-MPI without AC (non-corrected; BH-NC), free-breathing SPECT-MPI with AC (FB-AC), and breath-hold SPECT-MPI with AC (BH-AC), the latter representing respiratory-phase-matched AC SPECT-MPI. We compared semi-quantitative segmental tracer uptake, visual diagnosis, inter-observer agreement, and image quality. Compared with FB-NC, deep-inspiration BH-NC increases inferior and lateral uptake, but decreases septal uptake. Addition of AC to FB increases inferior and septal uptake, but decreases anterolateral uptake. Combining breath-hold MPI with breath-hold CT AC (BH-AC) increases inferior, inferolateral, and septal uptake, but reduces apical uptake, without affecting anterolateral uptake, with significant differences to all other protocols. Frequency of normal scans increases across protocols: 10% with FB-NC, 21% with BH-NC, 38% with FB-AC, and 51% with BH-AC. Image quality and inter-observer agreement were highest for BH-AC among all protocols. CONCLUSION: Compared with non-corrected breath-hold SPECT-MPI and with free-breathing AC SPECT-MPI, respiratory-phase-matched AC SPECT-MPI significantly affects segmental semi-quantitative uptake, increases the frequency of normal scans, yields the best inter-observer agreement, and significantly improves image quality. These findings suggest a potential role of respiratory triggered SPECT-MPI in clinical routine.

Fused cardiac hybrid imaging with coronary computed tomography angiography and positron emission tomography in patients with complex coronary artery anomalies.

OBJECTIVE: To provide data on the value of fused cardiac hybrid imaging with coronary computed tomography angiography (CCTA) and positron emission tomography myocardial perfusion imaging (PET-MPI) in patients with complex coronary artery anomalies (CCAA). DESIGN/SETTING: This is a retrospective, single-center study. PATIENTS: Seven consecutive patients with CCAA (mean 57 ± 7 y, 86% were male) who underwent clinically indicated hybrid CCTA/PET-MPI between 2005 and 2015 in our clinic were included. The findings from both modalities and fused cardiac hybrid imaging were evaluated in these patients. RESULTS: Out of the seven patients with CCAA, two patients had Bland-White-Garland anomaly, two patients showed a coronary artery fistula, two patients showed a "single right," and one patient showed a "single left" coronary artery. Semiquantitative fused hybrid CCTA/PET-MPI depicted inferolateral scar matching the territory of a nonanomalous vessel with significant concomitant coronary artery disease (CAD) in one patient only. In contrast, analysis of quantitative myocardial blood flow (MBF) as assessed by fused hybrid CCTA/PET-MPI revealed abnormally reduced flow capacities in the territories subtended by the anomalous vessels in 4 patients. CONCLUSIONS: In this case series of middle-aged patients with CCAA, perfusion defects as assessed by semiquantitative PET-MPI were rare and attributable to concomitant CAD rather than to the anomalous vessel itself. By contrast, impaired MBF as assessed by quantitative hybrid CCTA/PET-MPI was revealed in the majority of patients in the vessel territories subtended by the anomalous coronary artery itself. Fused hybrid CCTA/PET-MPI incorporating information on morphology and on semiquantitative and quantitative myocardial perfusions may provide added value for the management of patients with CCAA.

Hybrid CCTA/SPECT myocardial perfusion imaging findings in patients with anomalous origin of coronary arteries from the opposite sinus and suspected concomitant coronary artery disease.

BACKGROUND: Anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) are associated with adverse cardiac events. Discrimination between ACAOS and coronary artery disease (CAD)-related perfusion defects may be difficult. The aim of the present study was to investigate the value of hybrid coronary computed tomography angiography (CCTA)/SPECT-MPI in patients with ACAOS and possible concomitant CAD. METHODS: We retrospectively identified 46 patients (mean age 56 ± 12 years) with ACAOS revealed by CCTA who underwent additional SPECT-MPI. ACAOS with an interarterial course were classified as malignant, whereas all other variants were considered benign. CCTA/SPECT-MPI hybrid imaging findings (ischemia or scar) were analyzed according to the territory subtended by an anomalous vessel or a stenotic coronary artery. RESULTS: Twenty-six (57%) patients presented with malignant ACAOS. Myocardial ischemia or scar was found only in patients who had concomitant obstructive CAD in the vessel matching the perfusion defect as evidenced by hybrid CCTA/SPECT imaging. CONCLUSION: Hybrid CCTA/SPECT-MPI represents a valuable non-invasive tool to discriminate the impact of ACAOS from concomitant CAD on myocardial ischemia. Our results suggest that in a middle-aged population myocardial ischemia due to ACAOS per se may be exceedingly rare and is more likely attributable to concomitant CAD.

Adaptive Statistical Iterative Reconstruction-V: Impact on Image Quality in Ultralow-Dose Coronary Computed Tomography Angiography.

OBJECTIVE: The clinical utility of a latest generation iterative reconstruction algorithm (adaptive statistical iterative reconstruction [ASiR-V]) has yet to be elucidated for coronary computed tomography angiography (CCTA). This study evaluates the impact of ASiR-V on signal, noise and image quality in CCTA. METHODS: Sixty-five patients underwent clinically indicated CCTA on a 256-slice CT scanner using an ultralow-dose protocol. Data sets from each patient were reconstructed at 6 different levels of ASiR-V. Signal intensity was measured by placing a region of interest in the aortic root, LMA, and RCA. Similarly, noise was measured in the aortic root. Image quality was visually assessed by 2 readers. RESULTS: Median radiation dose was 0.49 mSv. Image noise decreased with increasing levels of ASiR-V resulting in a significant increase in signal-to-noise ratio in the RCA and LMA (P < 0.001). Correspondingly, image quality significantly increased with higher levels of ASiR-V (P < 0.001). CONCLUSIONS: ASiR-V yields substantial noise reduction and improved image quality enabling introduction of ultralow-dose CCTA.

Minimized Radiation and Contrast Agent Exposure for Coronary Computed Tomography Angiography: First Clinical Experience on a Latest Generation 256-slice Scanner.

RATIONALE AND OBJECTIVES: The aim of the study was to evaluate the impact of the latest coronary computed tomography angiography (CCTA) techniques allowing a radiation- and contrast-sparing protocol on image quality in unselected patients referred for exclusion of suspected coronary artery disease (CAD). MATERIALS AND METHODS: This prospective study was approved by the local ethics committee, and all patients provided written informed consent. Between March and June 2015, 89 consecutive patients (61% male; mean age 55 ± 11 years) referred for exclusion of CAD by 256-slice CCTA using prospective electrocardiogram triggering were included. Tube voltage (80-120 kVp), tube current (180-310 mA) as well contrast agent volume (25-45 mL) and flow rate (3.5-5 mL/s) were adapted to body mass index. Signal intensity was measured by placing a region of interest in the aortic root, the left main artery, and the proximal right coronary artery. Image noise was measured in the aortic root. Two independent blinded readers semi-quantitatively assessed the image quality regarding motion, noise, and contrast on a 4-point scale. RESULTS: Median contrast agent volume and median effective radiation dose were 35 mL (interquartile range, 30-40 mL) and 0.5 mSv (interquartile range, 0.4-0.6 mSv), respectively. Mean attenuation in the aortic root was 412 ± 89 Hounsfield units. Diagnostic image quality was obtained in 1050 of 1067 (98.4%) coronary segments and, on an intention-to-diagnosis basis, in 85 of 89 (95.5%) patients. Below a cut-off heart rate of 67 beats/min, only 1 of 974 (0.1%) coronary segments was nondiagnostic. CONCLUSION: A radiation- and contrast-sparing protocol for CCTA on a latest generation 256-slice computed tomography scanner yields diagnostic image quality in patients referred for CAD exclusion in daily clinical routine.

Impact of percutaneous mitral valve repair using the MitraClip system on tricuspid regurgitation.

AIMS: Tricuspid regurgitation (TR) severity and right ventricular (RV) dysfunction have been identified as significant predictors of outcome after mitral valve surgery. The aim of the present study was to investigate the impact of percutaneous mitral valve repair (PMVR) with the MitraClip system on functional TR severity and RV function. METHODS AND RESULTS: Among 119 consecutive patients with severe mitral regurgitation who underwent PMVR, 67 had complete baseline and follow-up transthoracic echocardiography after 3-12 months (6.8±2.9 months). TR severity was graded as mild, moderate, and severe. RV systolic function was assessed by fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE). Clinical endpoints at follow-up included mortality, reoperation of the mitral valve, hospitalisation for congestive heart failure and New York Heart Association (NYHA) functional class. After PMVR, a significant decrease in TR severity (by at least one grade) was observed in 22 (33%) patients, while an increase occurred in only seven (10%) patients (p=0.02). Overall, systolic RV function (FAC and TAPSE), RV dimensions, and tricuspid annular diameter did not change significantly. Baseline SPAP was significantly higher (57±15 vs. 43±14 mmHg, p=0.002) and SPAP reduction significantly larger (-14±13 versus 1±15 mmHg, p=0.012) in patients who improved their TR. Multivariate logistic regression analysis identified the change in SPAP as the only significant predictor of changes in TR (odds ratio [OR] [for every change in SPAP by 10 mmHg] 1.90, 95% CI: 1.02±3.54; p=0.044). Patients with mild/moderate TR at follow-up after PMVR had lower event rates compared to those with severe TR (35% vs. 78%, respectively, p=0.025). CONCLUSIONS: PMVR using the MitraClip device improves functional TR severity in approximately one third of patients, particularly in those who experience a significant SPAP reduction after the procedure.

Prevalence and characteristics of coronary artery anomalies detected by coronary computed tomography angiography in 5 634 consecutive patients in a single centre in Switzerland.

STUDY PRINCIPLES: Coronary computed tomography angiography (CCTA) allows three-dimensional visualisation of the origin, course and ending of the coronary vessels with high spatial resolution, yielding an accurate depiction of coronary artery anomalies (CAAs). This study sought to determine the prevalence, incidence and characteristics of CAAs detected with CCTA in a single centre in Switzerland. METHODS: CAAs were retrospectively identified in 5 634 consecutive patients referred for CCTA between March 2007 and July 2015. Single coronary arteries, Bland-White-Garland syndrome, anomalous coronary arteries originating from the opposite site of the sinus of Valsalva (ACAOS) with an interarterial course and coronary artery fistulas were classified as potentially malignant CAAs. RESULTS: We identified 145 patients with CAAs, resulting in an overall prevalence of 2.6% and cumulative incidence of 2.1% in all patients referred for CCTA in the observation period. Forty-nine (33.8%) patients showed malignant CAAs including 1 (0.7%) patient with Bland-White-Garland syndrome, 7 (4.8%) with single coronary arteries, 36 (24.8%) with ACAOS and an interarterial course, and 5 (3.5%) with coronary artery fistulas. The remaining 96 (66.2%) patients were classified as having benign variants. CONCLUSIONS: The prevalence of CAA detected by CCTA is not negligible. Because of its noninvasive nature, relatively low cost and low radiation exposure, a further increase in the utilisation of CCTA may be expected, which may consequently be paralleled by an increasing absolute number of incidentally detected CAAs. Hence, awareness of the main issues and possible management strategies regarding CAAs is of importance for every treating physician.

Association of left bundle branch block with obstructive coronary artery disease on coronary CT angiography: a case-control study.

AIMS: Left bundle branch block (LBBB) is considered an unfavourable prognostic marker in patients with underlying heart disease. Testing for coronary artery disease (CAD) is often prompted by incidental LBBB finding, but published studies disagree about a significant association between LBBB and CAD. We therefore assessed the association of LBBB with previously unknown CAD in patients undergoing coronary computed tomography angiography (CCTA). METHODS AND RESULTS: We enrolled 818 patients (mean age 57.2 ± 11.1 years, 106 patients with presumably new LBBB and 712 controls) without known CAD who underwent 64-slice CCTA. Image quality was assessed for each coronary segment. Comparison of obstructive CAD prevalence (defined as ≥50% stenosis) was performed using triple case-matching for pre-test probability (based on age, gender, and symptom typicality) in 101 LBBB patients and 303 matched controls with diagnostic quality in all segments. We found no difference in obstructive CAD prevalence between LBBB patients and matched controls (15 vs. 16%, P = 0.88). Similarly, there were no significant differences in cardiovascular risk factors (CVRF), stenosis severity, CAD extent, non-obstructive CAD, and vessel-based analysis between patient groups. Image quality was very high in LBBB patients and comparable to controls. On multivariate analysis, age, gender, typical angina, and CVRF, but not LBBB (P = 0.94), emerged as significant and independent predictors of obstructive CAD. CONCLUSION: CAD prevalence is similar in LBBB patients at low-to-moderate pre-test probability compared with controls with similar CVRF matched for age, gender, and symptom typicality. CCTA is a useful imaging modality in LBBB patients, providing comparable image quality to non-LBBB controls.

Quantification of epicardial and intrathoracic fat volume does not provide an added prognostic value as an adjunct to coronary artery calcium score and myocardial perfusion single-photon emission computed tomography.

AIMS: To compare the predictive value of epicardial and intrathoracic fat volume (EFV, IFV), coronary artery calcium (CAC) score, and single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) for major adverse cardiac events (MACE). METHODS AND RESULTS: Follow-up was obtained in 275 patients with known or suspected coronary artery disease (CAD), who underwent SPECT-MPI including non-contrast cardiac computed tomography (CT) for attenuation correction to evaluate ischaemic heart disease and in whom EFV, IFV, and CAC score were calculated from non-contrast CT. Associations between fat volume, traditional cardiovascular risk factors, CAC score, and SPECT-MPI results were assessed and MACE predictors identified by Cox proportional hazard regression and global χ(2) statistics. After a median follow-up of 2.9 years, MACE were recorded in 38 patients. In univariate Cox regression analysis, EFV and IFV were predictors of MACE (P = 0.013 and P = 0.004, respectively). In multivariate analysis, EFV and IFV provided incremental predictive value beyond traditional cardiovascular risk factors (P < 0.05 and P < 0.01). However, after adjustment for CAC score and SPECT-MPI results, EFV and IFV fell short of statistical significance as independent outcome predictors. CONCLUSION: Quantification of EFV and IFV is associated with MACE and may improve risk stratification beyond traditional cardiovascular risk factors. However, once CAC score and/or SPECT-MPI results are known, EFV and IFV do not provide any added clinically relevant prognostic value. Further studies may identify the subpopulation with the largest relative merit of EFV and IFV as an adjunct to SPECT-MPI and CAC score.