Pulse wave velocity and flow in the carotid artery versus the aortic arch: effects of aging.

PURPOSE: To explore differences in arterial stiffness of the aorta and carotid artery, assessed by pulse wave velocity (PWV), to evaluate the blood flow volume distribution towards the carotid circulation and to assess the effect of aging on the coupling between aortic and carotid PWV using velocity-encoded magnetic resonance imaging (MRI). MATERIALS AND METHODS: Sixteen adult younger volunteers (age <30 years) and 16 older volunteers (age >45 years) underwent 3T MRI examination to assess aortic and carotid flow volumes and PWV using the transit time method. RESULTS: Aortic versus carotid PWV-ratio was 1.2 for younger volunteers and 0.95 for older volunteers, demonstrating leveling of wall stiffness. Furthermore, flow volume per minute in the internal carotid artery was lower for older versus younger volunteers (mean volume 177 ± 42 mL/min/m(2) vs. 147 ± 32 mL/min/m(2), P = 0.028), whereas aorta and common carotid artery flow volumes were not different. Consequently, the fraction of blood flow volume towards the brain was smaller for older versus younger volunteers (61 ± 9% versus 71 ± 8%, P = 0.002). CONCLUSION: PWV-leveling between aorta and carotid artery at older age is associated with a reduction in blood flow volume towards the brain. Velocity-encoded MRI can be used to evaluate PWV and flow volume distribution in the aortic arch and the carotid circulation.

Acute coronary syndrome with a totally occluded culprit artery: relation of the ST injury vector with ST-elevation and non-ST elevation ECGs.

BACKGROUND: In acute coronary syndrome (ACS), ST-segment elevation (STE), often associated with a completely occluded culprit artery, is an important ECG criterion for primary percutaneous coronary intervention (PCI). However, several studies showed that in ACS a completely occluded culprit artery can also occur with a non-ST-elevation (NSTE) ECG. In order to elucidate reasons for this discrepancy we examined ST injury vector orientation and magnitude in ACS patients with and without STE, all admitted for primary PCI and having a completely occluded culprit artery. METHODS: We studied the ECGs of 300 ACS patients (214/86 STE/NSTE; 228/72 single/multivessel disease) who had a completely occluded culprit artery during angiography prior to primary PCI. The J+60 injury vector orientation and magnitude were computed from Frank XYZ leads derived from the 10-s standard 12-lead ECG. RESULTS: Demographic and anthropomorphic characteristics of the STE and NSTE patients did not differ. STE patients had a higher rate of right coronary artery occlusions, and a lower rate of left circumflex occlusions than NSTE patients (43 vs. 31%, and 13 vs. 22%, respectively; P<0.05). Injury vector elevation and magnitude were larger in STE than in NSTE patients (32° ± 37° vs. 6° ± 39°, and 304 ± 145 µV vs. 134 ± 72 µV, respectively; P<0.0001). CONCLUSION: STE criteria favor certain injury vector directions and larger injury vector magnitudes. Obviously, several ACS patients with complete culprit artery occlusions requiring primary PCI do not fulfill these criteria. Our study suggests that STE-NSTE-based ACS stratification needs further enhancement.

Efficacy and safety of low-dose digoxin in patients with heart failure. Rationale and design of the DECISION trial.

AIMS: Digoxin is the oldest drug in cardiovascular (CV) medicine, and one trial conducted >25 years ago showed a reduction in heart failure (HF) hospitalizations but no effect on mortality. However, later studies suggested that the dose of digoxin used in that trial (and other studies) may have been too high. The DECISION (Digoxin Evaluation in Chronic heart failure: Investigational Study In Outpatients in the Netherlands) trial will examine the efficacy and safety of low-dose digoxin in HF patients with reduced or mildly reduced left ventricular ejection fraction (LVEF) with a background of contemporary HF treatment. METHODS: The DECISION trial is a randomized, double-blind, parallel-group, placebo-controlled event-driven outcome trial which will investigate the efficacy and safety of low-dose digoxin in patients with chronic HF and LVEF <50%. Both patients with sinus rhythm and atrial fibrillation will be enrolled and will be randomized (1:1) to low-dose digoxin or matching placebo. To maintain a target serum digoxin concentration of 0.5-0.9 ng/ml, dose adjustments are made throughout follow-up based on serum digoxin measurements with dummy values for the placebo group. The primary endpoint is a composite of CV mortality and total HF hospitalizations or total urgent hospital visits for worsening HF, and all endpoints are adjudicated blindly by a Clinical Event Committee. The estimated sample size was 982 patients who will be followed for a median of 3 years, and in December 2023 enrolment was completed after 1002 patients. CONCLUSIONS: The DECISION trial will provide important evidence regarding the effect of (low-dose) digoxin on CV mortality and total HF hospitalizations and urgent hospital visits when added to contemporary HF treatment of patients with reduced or mildly reduced LVEF. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03783429.

The maximum necrotic core area is most often located proximally to the site of most severe narrowing: a virtual histology intravascular ultrasound study.

Previous angiographic studies have shown that almost two-thirds of vulnerable plaques are located in non-obstructive lesions. Possibly, the maximum necrotic core (Max NC) area is not always identical to the site of most severe stenosis. Therefore, the purpose of this study was to evaluate the potential difference in location between the maximum necrotic core area and the site of most severe narrowing as assessed by virtual histology intravascular ultrasound (VH IVUS). Overall, 77 patients (139 vessels) underwent VH IVUS. The Max NC site was defined as the cross section with the largest necrotic core area per vessel. The site of most severe narrowing was defined as the minimum lumen area (MLA). Per vessel, the distance from both the Max NC site and MLA site to the origo of the coronary artery was evaluated. In addition, the presence of a virtual histology-thin cap fibroatheroma (VH-TCFA) was assessed. The mean difference (mm) between the MLA site and Max NC site was 10.8 ± 20.6 mm (p < 0.001). Interestingly, the Max NC site was located at the MLA site in seven vessels (5%) and proximally to the MLA site in 92 vessels (66%). Importantly, a higher percentage of VH-TCFA was demonstrated at the Max NC site as compared to the MLA site (24 vs. 9%, p < 0.001). In conclusion, the present findings demonstrate that the Max NC area is rarely at the site of most severe narrowing. Most often, the Max NC area is located proximal to the site of most severe narrowing.

Prognostic value of coronary vessel dominance in relation to significant coronary artery disease determined with non-invasive computed tomography coronary angiography.

AIMS: Limited information is available regarding the relationship between coronary vessel dominance and prognosis. Therefore, the purpose of this study was to determine the prognostic value of coronary vessel dominance in relation to significant coronary artery disease (CAD) in patients referred for computed tomography coronary angiography (CTA). METHODS AND RESULTS: The study population consisted of 1425 patients (869 men, 57 ± 12 years) referred for CTA. To evaluate the impact of vessel dominance and significant CAD on CTA on outcome, patients were followed during a median period of 24 months for the occurrence of non-fatal myocardial infarction and all-cause mortality. The presence of a left dominant system was identified as a significant predictor for non-fatal myocardial infarction and all-cause mortality (HR: 3.20; 95% CI: 1.67-6.13, P < 0.001) and had incremental value over baseline risk factors and severity of CAD on CTA. In addition, in the subgroup of patients with significant CAD on CTA, patients with a left dominant system had a worse outcome compared with patients with a right dominant system (cumulative event rates: 9.5% and 35% at 3-year follow-up for a right and left dominant coronary artery system, respectively, log-rank P < 0.001). CONCLUSIONS: The presence of a left dominant system was identified as an independent predictor of non-fatal myocardial infarction and all-cause mortality, especially in patients with significant CAD on CTA. Therefore, the assessment of coronary vessel dominance on CTA may further enhance risk stratification beyond the assessment of significant CAD on CTA.

Reproducibility of planar (123)I-meta-iodobenzylguanidine (MIBG) myocardial scintigraphy in patients with heart failure.

PURPOSE: Despite its high prognostic value, widespread clinical implementation of (123)I-meta-iodobenzylguanidine (MIBG) myocardial scintigraphy is hampered by a lack of validation and standardization. The purpose of this study was to assess the reliability of planar (123)I-MIBG myocardial scintigraphy in patients with heart failure (HF). METHODS: Planar myocardial MIBG images of 70 HF patients were analysed by two experienced and one inexperienced observer. The reproducibility of early and delayed heart-to-mediastinum (H/M) ratios, as well as washout rate (WR) calculated by two different methods, was assessed using the intraclass correlation coefficient (ICC) and the Bland-Altman analysis. In addition, a subanalysis in patients with a very low H/M ratio (delayed H/M ratio <1.4) was performed. The delayed H/M ratio was also assessed using fixed-size oval and circular cardiac regions of interest (ROI). RESULTS: Intra- and interobserver analyses and experienced versus inexperienced observer analysis showed excellent agreement for the measured early and delayed H/M ratios and WR on planar (123)I-MIBG images (the ICCs for the delayed H/M ratios were 0.98, 0.96 and 0.90, respectively). In addition, the WR without background correction resulted in higher reliability than the WR with background correction (the interobserver Bland-Altman 95 % limits of agreement were -2.50 to 2.16 and -10.10 to 10.14, respectively). Furthermore, the delayed H/M ratio measurements remained reliable in a subgroup of patients with a very low delayed H/M ratio (ICC 0.93 for the inter-observer analysis). Moreover, a fixed-size cardiac ROI could be used for the assessment of delayed H/M ratios, with good reliability of the measurement. CONCLUSION: The present study showed a high reliability of planar (123)I-MIBG myocardial scintigraphy in HF patients, confirming that MIBG myocardial scintigraphy can be implemented easily for clinical risk stratification in HF.

Evaluation of sampling density on the accuracy of aortic pulse wave velocity from velocity-encoded MRI in patients with Marfan syndrome.

PURPOSE: To evaluate the effect of spatial (ie, number of sampling locations along the aorta) and temporal sampling density on aortic pulse wave velocity (PWV) assessment from velocity-encoded MRI in patients with Marfan syndrome (MFS). MATERIALS AND METHODS: Twenty-three MFS patients (12 men, mean age 36 ± 14 years) were included. Three PWV-methods were evaluated: 1) reference PWV(i.p.) from in-plane velocity-encoded MRI with dense temporal and spatial sampling; 2) conventional PWV(t.p.) from through-plane velocity-encoded MRI with dense temporal but sparse spatial sampling at three aortic locations; 3) EPI-accelerated PWV(t.p.) with sparse temporal but improved spatial sampling at five aortic locations with acceleration by echo-planar imaging (EPI). RESULTS: Despite inferior temporal resolution, EPI-accelerated PWV(t.p.) showed stronger correlation (r = 0.92 vs. r = 0.65, P = 0.03) with reference PWV(i.p.) in the total aorta, with less error (8% vs. 16%) and variation (11% vs. 27%) as compared to conventional PWV(t.p.) . In the aortic arch, correlation was comparable for both EPI-accelerated and conventional PWV(t.p.) with reference PWV(i.p.) (r = 0.66 vs. r = 0.67, P = 0.46), albeit 92% scan-time reduction by EPI-acceleration. CONCLUSION: Improving spatial sampling density by adding two acquisition planes along the aorta results in more accurate PWV assessment, even when temporal resolution decreases. For regional PWV assessment in the aortic arch, EPI-accelerated and conventional PWV assessment are comparably accurate. Scan-time reduction makes EPI-accelerated PWV assessment the preferred method of choice.

Update on small-diameter implantable cardioverter-defibrillator leads performance.

BACKGROUND: The performance of small diameter implantable cardioverter defibrillator (ICD) leads is questionable. However, data on performance during long-term follow-up are scarce. The aim of this study is to provide an update for the lead failure and cardiac perforation rate of Medtronic's Sprint Fidelis ICD lead (Medtronic Inc., Minneapolis, MN, USA) and St. Jude Medical's Riata ICD lead (St. Jude Medical Inc., St. Paul, MN, USA). METHODS: Since 1996, all ICD system implantations at the Leiden University Medical Center, the Netherlands, are registered. For this study, data up to February 2011 on 396 Sprint Fidelis leads (follow-up 3.4 ± 1.5 years), 165 8-French (F) Riata leads (follow-up 4.6 ± 2.6 years), and 30 7-F Riata leads (follow-up 2.9 ± 1.3 years) were compared with a benchmark cohort of 1,602 ICD leads (follow-up 3.4 ± 2.7 years) and assessed for the occurrence of lead failure and cardiac perforation. RESULTS: During follow-up, the yearly lead failure rate of the Sprint Fidelis lead, 7-F Riata lead, 8-F Riata lead, and the benchmark cohort was 3.54%, 2.28%, 0.78%, and 1.14%, respectively. In comparison to the benchmark cohort, the adjusted hazard ratio of lead failure was 3.7 (95% confidence interval [CI] 2.4-5.7, P < 0.001) for the Sprint Fidelis lead and 4.2 (95% CI 1.0-18.0, P < 0.05) for the 7-F Riata lead. One cardiac perforation was observed (3.3%) in the 7-F Riata group versus none in the 8-F Riata and Sprint Fidelis lead population. CONCLUSION: The current update demonstrates that the risk of lead failure during long-term follow-up is significantly increased for both the Sprint Fidelis and the 7-F Riata lead in comparison to the benchmark cohort. Only one cardiac perforation occurred.

Role of the vectorcardiogram-derived spatial QRS-T angle in diagnosing left ventricular hypertrophy.

INTRODUCTION: Current criteria for electrocardiographic (ECG) diagnosis of left ventricular hypertrophy (LVH) have a low diagnostic accuracy. Addition of demographic, anthropomorphic, and additional ECG variables may improve accuracy. As hypertrophy affects action potential morphology and intraventricular conduction, QRS prolongation and T-wave morphology may occur and become manifest in the vectorcardiographic variables spatial QRS-T angle (SA) and spatial ventricular gradient. In this study, we attempted to improve the diagnostic accuracy for LVH by using a combination of demographic, anthropomorphic, ECG, and vectorcardiographic variables. METHODS: The study group (n = 196) was divided in 4 subgroups with, on one hand, echocardiographically diagnosed LVH or a normal echocardiogram and, on the other hand, with any of the conventional ECG signs for LVH or with normal ECGs. Each subgroup was randomly split into halves, yielding 2 equally-sized (n = 98) data sets A and B. Age, sex, height, weight, body mass index, body surface area (BSA), frontal QRS axis, QRS duration, QT duration, maximal QRS vector magnitude, SA, and ventricular gradient magnitude and orientation were univariate studied by receiver operating characteristic analysis and were used to build a stepwise linear discriminant model using P < .05 as entry and P > .10 as removal criterion. The discriminant model was built in set A (model A) and tested on set B. Stability checks were done by building a discriminant model on set B and testing on set A and by cross-validation analysis in the complete study group. RESULTS: The discriminant model equation was D = 5.130 × BSA - 0.014 × SA - 8.74, wherein D greater than or equal to 0 predicts a normal echocardiogram and D less than 0 predicts LVH. The diagnostic accuracy (79%) was better than the diagnostic accuracy of conventional ECG criteria for LVH (57%). CONCLUSION: The combination of BSA and SA yields a diagnostic accuracy of LVH that is superior to that of the conventional ECG criteria.

Diagnosis and mortality prediction in pulmonary hypertension: the value of the electrocardiogram-derived ventricular gradient.

PURPOSE: The aim of this study was to investigate the use of the electrocardiogram-derived ventricular gradient, projected on the x-axis (VGx), for detection of pulmonary hypertension (PH) and for prediction of all-cause mortality in PH patients. METHODS: In patients referred for PH screening (n = 216), the VGx was calculated semiautomatically from the electrocardiogram and was defined as abnormal when less than 24 mV · ms. The VGx of PH patients was compared with the VGx of patients without PH. The association between a reduced VGx and mortality was investigated in PH patients. RESULTS: Patients with PH (n = 117) had a significantly reduced VGx: 14 ± 27 vs 45 ± 23 mV · ms, P < .001. Furthermore, a severely reduced VGx (<0 mV · ms) was associated with increased mortality in PH patients: hazard ratio, 1.025 (95% confidence interval, 1.006-1.045; P = .012) per mV·ms VGx decrease. CONCLUSION: Reduced VGx is associated with the presence of PH and, more importantly, within PH patients, a severely reduced VGx predicts mortality.

Diagnostic performance of non-invasive multidetector computed tomography coronary angiography to detect coronary artery disease using different endpoints: detection of significant stenosis vs. detection of atherosclerosis.

AIMS: The positive predictive value of multidetector computed tomography angiography (CTA) for detecting significant stenosis remains limited. Possibly CTA may be more accurate in the evaluation of atherosclerosis rather than in the evaluation of stenosis severity. However, a comprehensive assessment of the diagnostic performance of CTA in comparison with both conventional coronary angiography (CCA) and intravascular ultrasound (IVUS) is lacking. Therefore, the aim of the study was to systematically investigate the diagnostic performance of CTA for two endpoints, namely detecting significant stenosis (using CCA as the reference standard) vs. detecting the presence of atherosclerosis (using IVUS as the reference of standard). METHODS AND RESULTS: A total of 100 patients underwent CTA followed by both CCA and IVUS. Only those segments in which IVUS imaging was performed were included for CTA and quantitative coronary angiography (QCA) analysis. On CTA, each segment was evaluated for significant stenosis (defined as ≥ 50% luminal narrowing), on CCA significant stenosis was defined as a stenosis ≥ 50%. Second, on CTA, each segment was evaluated for atherosclerotic plaque; atherosclerosis on IVUS was defined as a plaque burden of ≥ 40% cross-sectional area. CTA correctly ruled out significant stenosis in 53 of 53 (100%) patients. However, nine patients (19%) were incorrectly diagnosed as having significant lesions on CTA resulting in sensitivity, specificity, positive, and negative predictive values of 100, 85, 81, and 100%. CTA correctly ruled out the presence of atherosclerosis in 7 patients (100%) and correctly identified the presence of atherosclerosis in 93 patients (100%). No patients were incorrectly classified, resulting in sensitivity, specificity, positive, and negative predictive values of 100%. Conclusions The present study is the first to confirm using both CCA and IVUS that the diagnostic performance of CTA is superior in the evaluation of the presence or the absence of atherosclerosis when compared with the evaluation of significant stenosis.

Site of latest activation in patients eligible for cardiac resynchronization therapy: patterns of dyssynchrony among different QRS configurations and impact of heart failure etiology.

INTRODUCTION: Cardiac resynchronization therapy (CRT) has emerged as a treatment option for patients with end-stage heart failure and a QRS duration ≥120 ms. Nonetheless, many patients with a prolonged QRS do not demonstrate left ventricular (LV) mechanical dyssynchrony, and discrepancies between electrical and mechanical dyssynchrony have been observed. In addition, several studies demonstrated that superior benefits after CRT could be achieved when the LV pacing lead was positioned at the most delayed myocardial segment. METHODS: A total of 248 heart failure patients scheduled for CRT were included. In all patients, a 12-lead electrocardiogram and 2-dimensional echocardiogram were obtained. Patients were divided into 5 QRS configuration subgroups: narrow, left bundle-branch block, right bundle-branch block, intraventricular conduction delay, and right ventricular pacing. With speckle-tracking radial strain analysis, we evaluated time to peak radial strain. Next, the segments with the least and with the most mechanical activation delay were identified, and LV dyssynchrony was defined as the time delay between the two. RESULTS: Mean QRS duration was 164 ± 31 ms. Mean LV dyssynchrony in all patients was 186 ± 122 ms. Site of latest activation was predominantly located in the lateral (27%), posterior (26%), and inferior (20%) segments. Furthermore, extent of LV dyssynchrony was comparable between QRS configuration subgroups. An unequal distribution of LV segments with the most mechanical delay was observed in the left bundle-branch block and right ventricular pacing subgroups (P < .001 for both), whereas in the narrow, right bundle-branch block, and intraventricular conduction delay subgroups, a more homogeneous distribution was noted. No differences in distribution pattern or in extent of LV dyssynchrony were observed between ischemic and nonischemic heart failure patients. CONCLUSION: The lateral, posterior, and inferior segments take up 73% of the total latest activated segments in heart failure patients eligible for CRT. Presence of LV dyssynchrony can be observed in all QRS configurations. The site of latest activation may be outside the lateral or posterior segment, making echocardiographic assessment of LV dyssynchrony and site of latest activation a valuable technique to optimize patient outcome after CRT.

Optimal left ventricular lead position assessed with phase analysis on gated myocardial perfusion SPECT.

PURPOSE: The aim of the current study was to evaluate the relationship between the site of latest mechanical activation as assessed with gated myocardial perfusion SPECT (GMPS), left ventricular (LV) lead position and response to cardiac resynchronization therapy (CRT). METHODS: The patient population consisted of consecutive patients with advanced heart failure in whom CRT was currently indicated. Before implantation, 2-D echocardiography and GMPS were performed. The echocardiography was performed to assess LV end-systolic volume (LVESV), LV end-diastolic volume (LVEDV) and LV ejection fraction (LVEF). The site of latest mechanical activation was assessed by phase analysis of GMPS studies and related to LV lead position on fluoroscopy. Echocardiography was repeated after 6 months of CRT. CRT response was defined as a decrease of ≥15% in LVESV. RESULTS: Enrolled in the study were 90 patients (72% men, 67±10 years) with advanced heart failure. In 52 patients (58%), the LV lead was positioned at the site of latest mechanical activation (concordant), and in 38 patients (42%) the LV lead was positioned outside the site of latest mechanical activation (discordant). CRT response was significantly more often documented in patients with a concordant LV lead position than in patients with a discordant LV lead position (79% vs. 26%, p<0.01). After 6 months, patients with a concordant LV lead position showed significant improvement in LVEF, LVESV and LVEDV (p<0.05), whereas patients with a discordant LV lead position showed no significant improvement in these variables. CONCLUSION: Patients with a concordant LV lead position showed significant improvement in LV volumes and LV systolic function, whereas patients with a discordant LV lead position showed no significant improvements.

Left ventricular diastolic dyssynchrony assessed with phase analysis of gated myocardial perfusion SPECT: a comparison with tissue Doppler imaging.

PURPOSE: The aim of the current study was to evaluate the feasibility of phase analysis on gated myocardial perfusion SPECT (GMPS) for the assessment of left ventricular (LV) diastolic dyssynchrony in a head-to-head comparison with tissue Doppler imaging (TDI). METHODS: The population consisted of patients with end-stage heart failure of New York Heart Association functional class III or IV with a reduced LV ejection fraction of ≤ 35%. LV diastolic dyssynchrony was calculated using TDI as the maximal time delay between early peak diastolic velocities of two opposing left ventricle walls (diastolic mechanical delay). Significant LV diastolic dyssynchrony was defined as a diastolic mechanical delay of >55 ms on TDI. Furthermore, phase analysis on GMPS was performed to evaluate LV diastolic dyssynchrony; diastolic phase standard deviation (SD) and histogram bandwidth (HBW) were used as markers of LV diastolic dyssynchrony. RESULTS: A total of 150 patients (114 men, mean age 66.0 ± 10.4 years) with end-stage heart failure were enrolled. Both diastolic phase SD (r = 0.81, p < 0.01) and diastolic HBW (r = 0.75, p < 0.01) showed good correlations with LV diastolic dyssynchrony on TDI. Additionally, patients with LV diastolic dyssynchrony on TDI (>55 ms) showed significantly larger diastolic phase SD (68.1 ± 13.4° vs. 40.7 ± 14.0°, p < 0.01) and diastolic HBW (230.6 ± 54.3° vs. 129.0 ± 55.6°, p < 0.01) as compared to patients without LV diastolic dyssynchrony on TDI (≤ 55 ms). Finally, phase analysis on GMPS showed a good intra- and interobserver reproducibility for the determination of diastolic phase SD (ICC 0.97 and 0.88) and diastolic HBW (ICC 0.98 and 0.93). CONCLUSION: Phase analysis on GMPS showed good correlations with TDI for the assessment of LV diastolic dyssynchrony.

Diagnostic performance of 320-slice multidetector computed tomography coronary angiography in patients after coronary artery bypass grafting.

OBJECTIVES: To evaluate the diagnostic performance of 320-slice computed tomography coronary angiography (CTA) in the evaluation of patients with prior coronary artery bypass grafting (CABG). Invasive coronary angiography (ICA) served as the standard of reference, using a quantitative approach. METHODS: CTA studies were performed using CT equipment with 320 detector-rows, each 0.5 mm wide, and a gantry rotation time of 0.35 s. All grafts, recipient and nongrafted vessels were deemed interpretable or uninterpretable. The presence of significant (≥50%) stenosis and occlusion were determined on vessel and patient basis. Results were compared to ICA using quantitative coronary angiography. RESULTS: A total of 40 patients (28 men, 76 ± 15 years), with 89 grafts, were included in the study. On a graft analysis, the sensitivity, specificity, positive and negative predictive values in the evaluation of significant stenosis were 96%, 92%, 83% and 98% respectively. The diagnostic accuracy for the assessment of recipient and nongrafted vessels was 89% and 80%, respectively. The diagnostic accuracy for the assessment of graft, recipient and nongrafted vessel occlusion was 96%, 92% and 100%, respectively. CONCLUSIONS: 320-slice CTA allows accurate non-invasive assessment of significant graft, recipient vessel and nongrafted vessel stenosis in patients with prior CABG.

Comprehensive assessment of spotty calcifications on computed tomography angiography: comparison to plaque characteristics on intravascular ultrasound with radiofrequency backscatter analysis.

BACKGROUND: The purpose of the study was to systematically compare calcification patterns in plaques on computed tomography angiography (CTA) with plaque characteristics on intravascular ultrasound with radiofrequency backscatter analysis (IVUS-VH). METHODS AND RESULTS: In total, 108 patients underwent CTA and IVUS-VH. On CTA, calcification patterns in plaques were classified as non-calcified, spotty or dense calcifications. Plaques with spotty calcifications were differentiated into small spotty (<1 mm), intermediate spotty (1-3 mm) and large spotty calcifications (≥3 mm). Plaque characteristics deemed more high-risk on IVUS-VH were defined by % necrotic core (NC) and presence of thin cap fibroatheroma (TCFA). Overall, 300 plaques were identified both on CTA and IVUS-VH. % NC core was significantly higher in plaques with small spotty calcifications as compared to non-calcified plaques (20% vs 13%, P = .006). In addition, there was a trend for a higher % NC in plaques with small spotty calcifications than in plaques with intermediate spotty calcifications (20% vs 14%, P = .053). Plaques with small spotty calcifications had the highest % TCFA as compared to large spotty and dense calcifications (31% vs 9% and 31% vs 6%, P < .05). CONCLUSION: Plaques with small spotty calcifications on CTA were related to plaque characteristics deemed more high-risk on IVUS-VH. Therefore, CTA may be valuable in the assessment of the vulnerable plaque.

Subclinical left ventricular dysfunction and coronary atherosclerosis in asymptomatic patients with type 2 diabetes.

AIMS: The aim of the present study was to evaluate whether subclinical left ventricular (LV) systolic dysfunction is independently related to subclinical coronary atherosclerosis in type 2 diabetic patients and if it could provide incremental information over baseline characteristics to identify high-risk patients. METHODS AND RESULTS: A total of 234 asymptomatic, type 2 diabetic patients without overt LV systolic dysfunction underwent coronary artery calcium (CAC) scoring and two-dimensional echocardiography. The LV global longitudinal strain (GLS) was assessed using automated function imaging. Patients with coronary atherosclerosis (CAC > 0; n = 139) had more impaired GLS when compared with patients without coronary atherosclerosis (CAC = 0; n = 95; -18.0 ± 2.8 vs. -16.3 ± 3.0%, P < 0.001). At multivariate analysis, male gender, hypertension, hypercholesterolaemia, and the LV GLS were independently associated with coronary atherosclerosis. The addition of the LV GLS to other selected independent clinical variables significantly improved the ability to predict coronary atherosclerosis in these patients (χ(2) = 58.92; P = 0.001). CONCLUSION: Type 2 diabetic patients with coronary atherosclerosis showed a more impaired LV GLS compared with patients without coronary atherosclerosis. The presence of subclinical LV systolic dysfunction provides significant incremental value for the identification of diabetic patients having coronary atherosclerosis.

Influence of the vectorcardiogram synthesis matrix on the power of the electrocardiogram-derived spatial QRS-T angle to predict arrhythmias in patients with ischemic heart disease and systolic left ventricular dysfunction.

BACKGROUND AND PURPOSE: Several studies have demonstrated that the spatial mean QRS-T angle (SA) predicts cardiac events and mortality. Spatial mean QRS-T angle is a vectorcardiographic variable. Because in clinical practice, 12-lead standard electrocardiograms (ECGs) are recorded rather than vectorcardiograms (VCGs) according to Frank, VCGs are commonly obtained by synthesizing them from 12-lead ECGs, by using a VCG synthesis matrix. Hence, the thus computed SA is an estimate of the real SA measured in the Frank VCG. Recent studies have shown that Kors VCG synthesis matrix yields better estimates of SA than the inverse Dower VCG synthesis matrix. Our current study aims to compare the predictive power of these SA variants for the occurrence of potentially lethal arrhythmias. METHODS: The study group consisted of patients with ischemic heart disease and left ventricular systolic dysfunction who received an implantable cardioverter-defibrillator (ICD) for primary prevention. During follow-up, the occurrence of appropriate device therapy (occurrence of ventricular arrhythmia) was noted. Alternative SAs were computed in VCGs synthesized from standard 12-lead ECGs by using either the inverse Dower matrix (SA-Dower) or the Kors matrix (SA-Kors). Comparison of the predictive power of SA-Dower and SA- Kors was performed by receiver operating characteristic analysis, by Kaplan-Meier analysis, and by univariate and multivariate Cox regression analysis, using every 10th percentile of SA as a cutoff value. RESULTS: The study group consisted of 412 patients (361 men; mean ± SD age 63 ± 11 years), in which 56 patients had appropriate ICD therapy during follow-up. Receiver operating characteristic analysis revealed that the area under the curve of SA-Kors was significantly larger than area under the curve of SA-Dower (0.646 vs 0.607, P = .043). The discriminative power of SA-Kors for the absence/presence of appropriate ICD therapy in patients during follow-up was generally superior to SA-Dower over a wide range of cutoff values in the Kaplan-Meier analysis and generally yielded stronger hazard ratios in the univariate and multivariate Cox regression analyses. CONCLUSION: If there is no specific reason to use the inverse Dower matrix, VCG synthesis from standard 12-lead ECGs should preferably be done by using the Kors matrix. It is likely to assume that already published studies in which the predictive value of SA-Dower was demonstrated would yield stronger results if the SA-Dower angles were substituted by SA-Kors angles.

Predictive power of T-wave alternans and of ventricular gradient hysteresis for the occurrence of ventricular arrhythmias in primary prevention cardioverter-defibrillator patients.

BACKGROUND AND PURPOSE: Left ventricular ejection fraction lacks specificity to predict sudden cardiac death in heart failure. T-wave alternans (TWA; beat-to-beat T-wave instability, often measured during exercise) is deemed a promising noninvasive predictor of major cardiac arrhythmic event. Recently, it was demonstrated that TWA during recovery from exercise has additional predictive value. Another mechanism that potentially contributes to arrhythmogeneity is exercise-recovery hysteresis in action potential morphology distribution, which becomes apparent in the spatial ventricular gradient (SVG). In the current study, we investigated the performance of TWA amplitude (TWAA) during a complete exercise test and of exercise-recovery SVG hysteresis (SVGH) as predictors for lethal arrhythmias in a population of heart failure patients with cardioverter-defibrillators (ICDs) implanted for primary prevention. METHODS: We performed a case-control study with 34 primary prevention ICD patients, wherein 17 patients (cases) and 17 patients (controls) had no ventricular arrhythmia during follow-up. We computed, in electrocardiograms recorded during exercise tests, TWAA (maximum over the complete test) and the exercise-recovery hysteresis in the SVG. Statistical analyses were done by using the Student t test, Spearman rank correlation analysis, receiver operating characteristics analysis, and Kaplan-Meier analysis. Significant level was set at 5%. RESULTS: Both SVGH and TWAA differed significantly (P < .05) between cases (mean ± SD, SVGH: -18% ± 26%, TWAA: 80 ± 46 µV) and controls (SVGH: 5% ± 26%, TWAA: 49 ± 20 µV). Values of TWAA and SVGH showed no significant correlation in cases (r = -0.16, P = .56) and in controls (r = -0.28, P = .27). Receiver operating characteristics of SVGH (area under the curve = 0.734, P = .020) revealed that SVGH less than 14.8% discriminated cases and controls with 94.1% sensitivity and 41.2% specificity; hazard ratio was 3.34 (1.17-9.55). Receiver operating characteristics of TWA (area under the curve = 0.699, P = .048) revealed that TWAA greater than 32.5 µV discriminated cases and controls with 93.8% sensitivity and 23.5% specificity; hazard ratio was 2.07 (0.54-7.91). DISCUSSION AND CONCLUSION: Spatial ventricular gradient hysteresis bears predictive potential for arrhythmias in heart failure patients with an ICD for primary prevention, whereas TWA analysis seems to have lesser predictive value in our pilot group. Spatial ventricular gradient hysteresis is relatively robust for noise, and, as it rests on different electrophysiologic properties than TWA, it may convey additional information. Hence, joint analysis of TWA and SVGH may, possibly, improve the noninvasive identification of high-risk patients. Further research, in a large group of patients, is required and currently carried out by our group.

Morbidity and mortality in heart failure patients treated with cardiac resynchronization therapy: influence of pre-implantation characteristics on long-term outcome.

AIMS: Cardiac resynchronization therapy (CRT) improves cardiac function, heart failure symptoms, and prognosis in selected patients. Many baseline characteristics associated with heart failure may influence prognosis after CRT. The objective of this study was to evaluate the effect of several baseline characteristics in relation to long-term prognosis in heart failure patients treated with CRT. METHODS AND RESULTS: A total of 716 consecutive heart failure patients treated with CRT were included in an observational registry. All available data, including clinical and echocardiographic measurements, were analysed in relation to two endpoints: all-cause mortality and a combined endpoint of all-cause mortality or major cardiovascular event. Outcome data were collected by chart review, device interrogation, and telephone contact. Mean follow-up was 25 ± 19 months. During follow-up, 141 patients (20%) died (primary endpoint). Most of these patients (61%) died due to worsening heart failure. A total of 214 patients (30%) reached the secondary endpoint. Larger left ventricular end-systolic volume, less distance covered in the 6 min walking test, poor renal function, more severe heart failure, male gender, presence of atrial fibrillation, no posterolateral left ventricular (LV) lead, and no LV dyssynchrony were associated with poor prognosis after CRT. CONCLUSION: In this large single-centre registry, several baseline clinical and echocardiographic characteristics were associated with prognosis after CRT. Worsening heart failure was the main cause of death in heart failure patients treated with CRT.