The Feasibility of a Model-Based Iterative Reconstruction Technique Tuned for the Myocardium on Myocardial Computed Tomography Late Enhancement.

OBJECTIVES: This study evaluated the feasibility of a model-based iterative reconstruction technique (MBIR) tuned for the myocardium on myocardial computed tomography late enhancement (CT-LE). METHODS: Twenty-eight patients who underwent myocardial CT-LE and late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) within 1 year were retrospectively enrolled. Myocardial CT-LE was performed using a 320-row CT with low tube voltage (80 kVp). Myocardial CT-LE images were scanned 7 min after CT angiography (CTA) without additional contrast medium. All myocardial CT-LE images were reconstructed with hybrid iterative reconstruction (HIR), conventional MBIR (MBIR_cardiac), and new MBIR tuned for the myocardium (MBIR_myo). Qualitative (5-grade scale) scores and quantitative parameters (signal-to-noise ratio [SNR] and contrast-to-noise ratio [CNR]) were assessed as image quality. The sensitivity, specificity, and accuracy of myocardial CT-LE were evaluated at the segment level using an American Heart Association (AHA) 16-segment model, with LGE-MRI as a reference standard. These results were compared among the different CT image reconstructions. RESULTS: In 28 patients with 448 segments, 160 segments were diagnosed with positive by LGE-MRI. In the qualitative assessment of myocardial CT-LE, the mean image quality scores were 2.9 ± 1.2 for HIR, 3.0 ± 1.1 for MBIR_cardiac, and 4.0 ± 1.0 for MBIR_myo. MBIR_myo showed a significantly higher score than HIR (P < 0.001) and MBIR_cardiac (P = 0.018). In the quantitative image quality assessment of myocardial CT-LE, the median image SNR was 10.3 (9.1-11.1) for HIR, 10.8 (9.8-12.1) for MBIR_cardiac, and 16.8 (15.7-18.4) for MBIR_myo. The median image CNR was 3.7 (3.0-4.6) for HIR, 3.8 (3.2-5.1) for MBIR_cardiac, and 6.4 (5.0-7.7) for MBIR_myo. MBIR_myo significantly improved the SNR and CNR of CT-LE compared to HIR and MBIR_cardiac (P < 0.001). The sensitivity, specificity, and accuracy for the detection of myocardial CT-LE were 70%, 92%, and 84% for HIR; 71%, 92%, and 85% for MBIR_cardiac; and 84%, 92%, and 89% for MBIR_myo, respectively. MBIR_myo showed significantly higher image quality, sensitivity, and accuracy than the others (P < 0.05). CONCLUSIONS: MBIR tuned for myocardium improved image quality and diagnostic performance for myocardial CT-LE assessment.

Premature atrial contraction immediately after catheter ablation was associated with late recurrence of atrial fibrillation.

BACKGROUND: Although premature atrial contractions (PACs) just after catheter ablation (CA) for atrial fibrillation (AF) are common, their clinical significance is uncertain. This study aimed to evaluate whether the PAC burden after an initial CA for AF was associated with late recurrence. METHODS: We enrolled 346 patients with AF (median age, 65 years; 30% female; 57% with paroxysmal AF) who underwent an initial radiofrequency CA and a 24-h Holter monitoring the day after the procedure. PAC was defined as supraventricular complexes occurring ≥30% earlier than expected compared with a previous RR interval, and the number of PAC/24 h during post-procedural Holter monitoring was analyzed. RESULTS: AF recurred in 106 patients (31%) during a median follow-up of 19 months. These patients had significantly more PAC/24 h than those without (median [interquartile range], 891 [316-4351] beats vs. 409 [162-1,303] beats; p < 0.01). The number of PACs was independently associated with AF recurrence after adjustment for clinical parameters and left atrial (LA) enlargement. Receiver operating characteristic (ROC) curve analysis revealed that 1431 PAC/24 h was the optimal cut-off value for predicting AF recurrence. Adding the PAC/24 h to the prediction model with LA diameter appeared to correctly reclassify patients who were thought to be at high risk for AF recurrence into the low-risk group and vice versa. CONCLUSIONS: The number of PACs was an independent risk factor for AF recurrence. A 24-h Holter recording the day after an initial CA is a simple and beneficial tool for the risk stratification of AF recurrence.

Coronary artery-left ventricular shunt: an important cause of chest pain in patients with hypertrophic cardiomyopathy.

The influence of shunts between the coronary artery (CA) and the left ventricle (LV), on chest pain (CP) in patients with hypertrophic cardiomyopathy (HCM) is unknown. We examined the incidence of CA-LV shunts and their influence on CP in HCM patients. Twenty normal control subjects (NCS), 3 with CP due to CA-LV shunts (CP patients), and 60 with HCM participated. Interventricular septal wall thickness (IVST), LV posterior wall thickness (LVPWT), cardiac and stroke indexes (CI and SI), LV end-diastolic pressure (LVEDP), and proximal diameters of the CA were measured. Twenty-five HCM patients had a CA-LV shunt (41.7%). Both IVST and LVPWT were greater in the HCM patients than in NCS and CP patients. These values showed no significant differences between the HCM with shunt and HCM without shunt groups. CI and SI were lower in the HCM patients than in NCS and CP patients. LVEDP was higher in the HCM and CP patients than in NCS. CA diameters were larger in the HCM and CP patients than in NCS. CP was found in 32 HCM patients (53%). The incidence of CP was greater in the HCM with shunt group than in HCM without shunt group (80 vs. 34%, p < 0.0005). There was no significant difference in CA diameters between the HCM patients with CP and those without CP. CA-LV shunts are often found in HCM patients and are closely related to CP. Thus, CA-LV shunts are an important factor behind CP in HCM patients.

A prediction model for estimating NT-proBNP in a general Japanese population: the Toon Health Study.

AIMS: As part of the Toon Health Study, which is an ongoing population-based cohort study, we aimed to develop a prediction model for N-terminal pro-brain natriuretic peptide (NT-proBNP) in a general Japanese population. We sought to explore the influence of various demographic and clinical factors on NT-proBNP levels and assess the model's performance. In addition, our objectives included internal validation and investigation of the diagnostic potential of the observed-to-predicted NT-proBNP ratio (OPR) at baseline for predicting the risk of heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS: In this prospective cohort study, participants were recruited from Toon City, Japan, as part of the larger Toon Health Study, focusing on cardiovascular risk factors. We measured the NT-proBNP levels and used linear regression with penalization (ridge regression) to develop the model. The model incorporated 10 prespecified predictors (age, gender, body mass index, diastolic blood pressure, heart rate, haemoglobin, albumin, total cholesterol, haemoglobin A1c, and estimated glomerular filtration rate) and underwent assessment using R2 and root mean squared error (RMSE). Internal validation was conducted through bootstrapping. In a post hoc analysis, we explored the OPR's diagnostic potential using 5 year follow-up data (n = 636) to predict the elevation of NT-proBNP > 125 pg/mL at the 5 year follow-up as the risk of HFpEF. A total of 2505 participants (age: 60.4 ± 12.9 years, men: 35%) were enrolled in this study. There was a linear relationship between the observed and predicted values of NT-proBNP in which the logarithm of observed NT-proBNP was <6, which corresponds to 403 pg/mL in NT-proBNP. The prediction model demonstrated satisfactory performance (R2: 0.291, RMSE: 0.688), with age identified as a dominant predictor. The stability of the model was underscored by the internal validation. The OPR at baseline predicted NT-proBNP > 125 pg/mL at the 5 year follow-up with an area under the curve of 0.793. CONCLUSIONS: This study introduces the first prediction model for NT-proBNP in a general Japanese population. Although the model has acceptable performance, ongoing refinement is essential. Our transparent approach to model development, alongside a web-based interactive tool, lays the groundwork for further improvements and external validation. The OPR holds potential for predicting the future risk of HFpEF. This research contributes to understanding the nuanced influence of patient backgrounds on levels of NT-proBNP in asymptomatic individuals within the context of a broader population-based cohort study.

Remote dielectric sensing predicts elevated left atrial pressure in patients with atrial fibrillation.

Background: There are currently no established non-invasive indices of echocardiography for elevated left atrial pressure (LAP) especially in patients with atrial fibrillation (AF). Remote dielectric sensing (ReDS) is a novel non-invasive electromagnetic energy-based technology that quantifies total lung fluid, enabling the monitoring of volume status in patients with heart failure. The utility of ReDS for estimating LAP in patients with AF remains unknown. Methods: We prospectively investigated patients with AF in whom LAP was directly measured during catheter ablation for AF, and ReDS measurements were conducted the day before ablation. Elevated LAP was defined as LAP ≥ 15 mmHg. Results: A total of 61 patients were included (median age 66 years, 38 % female). Among them, 26 patients had elevated LAP. There was a positive correlation between ReDS and LAP (r = 0.363, P = 0.004). Receiver operating characteristic curve analysis for the prediction of elevated LAP demonstrated that the best cut-off value of ReDS was 30 %, with a sensitivity of 65 %, specificity of 69 %, and an area under the curve of 0.703 (95 % confidence interval 0.568-0.837). Multivariate logistic regression analysis revealed that ReDS was an independent predictor of elevated LAP, among covariates including left ventricular ejection fraction, the ratio of early transmitral flow velocity to septal mitral annular early diastolic velocity, and left atrial volume index. Conclusions: Our results suggest ReDS could be a valuable marker of elevated LAP even in patients with AF. Further studies are needed to elucidate the effectiveness of a ReDS-guided decongestive strategy in patients with heart failure.

Impact of Aromatase Inhibitors Treatment Duration on Coronary Artery Calcification in Postoperative Patients With Breast Cancer.

BACKGROUND: Aromatase inhibitors (AIs) are the standard therapeutic approach for hormone receptor-positive postmenopausal breast cancer. However, there are concerns about increased cardiovascular risk due to their antioestrogenic effects. This study aimed to investigate the potential association between duration of AI treatment and the severity of coronary artery calcification (CAC). METHODS: The study included outpatients who initiated adjuvant endocrine therapy with AIs for breast cancer from August 2010 to October 2022. CAC was quantified according to a visual ordinal scoring system. Patient characteristics were assessed based on the presence of CAC. Independent risk factors for elevated CAC scores were identified through a multivariable logistic regression model. RESULTS: Among 357 patients, 44.8% exhibited CAC. No significant difference in AI treatment duration was observed between groups (1268 d [interquartile range (IQR) 725-1743 d] vs 1104 d [IQR 685-1683.25 d]; P = 0.236). Patients with CAC were characterised by higher age (63.06 y [56.81-68.78 y] vs 74.39 y [68.98-80.03 y]; P < 0.001), lower hemoglobin levels (g/dL: 13.20L [IQR 12.60-13.70L] vs 12.60 [IQR 11.60-13.43]; P < 0.001), and reduced estimated glomerular filtration rate (mL/min/1.73 m2: 72.00 [IQR 61.80-81.50] vs 62.80 [IQR 51.27-71.90]; P < 0.001) compared with those without CAC. The prevalences of hypertension, diabetes mellitus, and dyslipidemia were significantly higher in patients with CAC. No correlation was found between the duration of AI treatment and CAC score (R = -0.02; P = 0.78). Independent risk factors for CAC included higher age, lower hemoglobin levels, and the presence of hypertension and diabetes mellitus in postoperative patients with breast cancer. CONCLUSIONS: The duration of AI treatment does not exert a significant influence on CAC in postoperative patients with breast cancer.

Evaluation of health utility in trial-based cost-utility analyses for major cardiovascular disease: protocol for a systematic review.

INTRODUCTION: The global incidence of cardiovascular disease (CVD) is high, and the medical costs associated with its management have been increasing. Cost-utility analyses (CUAs) are essential for understanding the value of healthcare interventions and for decision-making. A majority of the CUAs for CVD are model based and have cited health utilities from previously published data; standard health utilities for the CUAs of CVD have not been established yet. Thus, we aim to identify the standard utilities according to the patients' condition and disease severity in patients with major CVDs. METHODS AND ANALYSIS: We will search Medline and Evidence-Based Medicine Reviews for trial-based CUA studies that have reported on quality-adjusted life-years using original health utilities for patients with three major forms of CVD (coronary artery disease, heart failure and atrial fibrillation). Papers on trial-based CUAs will be included, while those on model-based CUAs will be excluded. No restrictions will be made in terms of intervention type. The main outcome comprises the health utilities calculated on a scale of 0-1 (irrespective of the measurement methods) at baseline and after treatment. Two independent investigators will screen the eligibility of articles; they will extract data, including health utilities, from the eligible articles for further analysis. The quality of the included studies will be assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist. We will describe the means and SDs of the health utilities from all the included studies. The mean utility weights for individual studies will be combined through meta-analyses using a random-effects model to obtain the representative health utility value for each disease. Subgroup analyses will be conducted according to the severity and duration of each disease. ETHICS AND DISSEMINATION: Ethical approval is not required. The review will be submitted to an appropriate peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42022316278.

A Novel Quantitative Parameter for Static Myocardial Computed Tomography: Myocardial Perfusion Ratio to the Aorta.

We evaluated the feasibility of myocardial perfusion ratio to the aorta (MPR) in static computed tomography perfusion (CTP) for detecting myocardial perfusion abnormalities assessed by single-photon emission computed tomography (SPECT). Twenty-five patients with suspected coronary artery disease who underwent dynamic CTP and SPECT were retrospectively evaluated. CTP images scanned at a sub-optimal phase for detecting myocardial perfusion abnormalities were selected from dynamic CTP images and used as static CTP images in the present study. The diagnostic accuracy of MPR derived from static CTP was compared to those of visual assessment and conventional quantitative parameters such as myocardial CT attenuation (HU) and transmural perfusion ratio (TPR). The area under the curve of MPR (0.84; 95% confidence interval [CI], 0.76−0.90) was significantly higher than those of myocardial CT attenuation (0.73; 95% CI, 0.65−0.79) and TPR (0.76; 95% CI, 0.67−0.83) (p < 0.05). Sensitivity and specificity were 67% (95% CI, 54−77%) and 90% (95% CI, 86−92%) for visual assessment, 51% (95% CI, 39−63%) and 86% (95% CI, 82−89%) for myocardial CT attenuation, 63% (95% CI, 51−74%) and 84% (95% CI, 80−88%) for TPR, and 78% (95% CI, 66−86%) and 84% (95% CI, 80−88%) for MPR, respectively. MPR showed higher diagnostic accuracy for detecting myocardial perfusion abnormality compared with myocardial CT attenuation and TPR.

Restricted left atrial dilatation can visually differentiate cardiac amyloidosis from hypertrophic cardiomyopathy.

AIMS: Cardiac amyloidosis (CA) is an infiltrative myocardial disease that occasionally mimics hypertrophic cardiomyopathy (HCM). The aim of this study is to investigate the discriminatory ability of visual assessment of left atrial (LA) function between CA and HCM on echocardiography. METHODS AND RESULTS: In total, 93 patients with cardiac magnetic resonance imaging (CMR)-confirmed HCM and 34 with cardiac biopsy-confirmed CA were retrospectively assessed. LA dilatation was assessed via echocardiography in an apical four-chamber view. Visual assessment was performed to identify LA dilatation grade (preserved = 1, abnormal = 2, and restricted = 3) based on the extent of outward expansion in the LA reservoir phase. Regarding the reproducibility of visually assessing LA dilatation grade, the kappa values between intra- and inter-observer measurements were 0.82 and 0.70, respectively. Of 127 participants, 57 (45%), 42 (33%), and 28 (22%) presented with LA dilatation Grades 1, 2, and 3, respectively. All 57 patients with preserved LA dilatation (Grade 1) had HCM, and 20 of 28 patients (71%) with restricted LA dilatation (Grade 3) presented with CA. Patients with CA had a higher LA dilatation grade than those with HCM (P < 0.01). LA emptying fraction and reservoir strain were also quantitatively evaluated. The area under the curves of LA dilatation grade (0.88) and LA emptying fraction (0.88) for differentiation of these two diseases were higher than that of LA reservoir strain (0.73) (P < 0.01, respectively). During follow-up, nine patients with HCM and 16 with CA experienced cardiac event (cardiac death or hospitalization due to heart failure). In Kaplan-Meier analysis including both groups of HCM and CA, the incidence of cardiac events was higher in patients with restricted LA dilatation than in those with preserved or abnormal LA dilatation (log-rank test, P < 0.01). CONCLUSIONS: Restricted LA dilatation is an indicator for the diagnosis of CA. Further, visual assessment of abnormal LA motion may facilitate diagnosis in patients with CA and high-risk patients with HCM.

Impact of chronic kidney disease on the diuretic response of tolvaptan in acute decompensated heart failure.

AIM: This study investigated the relationship between the initial diuretic response to tolvaptan and clinical predictors for tolvaptan responders in patients with acute decompensated heart failure (ADHF). METHODS AND RESULTS: Patients (153) with ADHF (clinical scenario 2 or 3 with signs of fluid retention) who were administered tolvaptan were enrolled. Tolvaptan (15 or 7.5 mg) was administered for at least 7 days to those patients in whom fluid retention was observed even after standard treatment. The maximum urine volume immediately after tolvaptan administration showed good correlations with the ejection fraction and estimated glomerular filtration rate that were independent predictors of the urine volume (UV) responders (≥1500 mL increase in urine volume). The diuretic response (in terms of maximum diuresis) diminished with advancing chronic kidney disease (CKD) stage and concomitant deterioration of the renal function. Furthermore, advanced CKD was a significant negative predictor for the body weight (BW) responders (2.0% decrease in the body weight within 1 week after starting tolvaptan). As compared with non-CKD, the presence of advanced CKD predicts poor diuretic response for both UV and BW responders. CONCLUSIONS: The diuretic response following tolvaptan administration gradually diminished with progressive deterioration of the CKD stage. Worsening renal function was not observed. Tolvaptan is effective in treating CS2 or CS3 ADHF patients who present fluid retention and congestion, suggesting its potential efficacy for fluid management in the ADHF patients with CKD without worsening the renal function.

Successful treatment of cerebral emboli with tissue plasminogen activator in a patient with takotsubo cardiomyopathy: A case report.

Takotsubo cardiomyopathy is a cardiac syndrome characterized by reversible left ventricular wall motion abnormalities. It mimics the acute coronary syndrome; however, significant obstructive coronary artery disease is absent. The prognosis is relatively favorable in many cases, but complications may occur during the acute stage. Herein, we present a case of takotsubo cardiomyopathy in a 76-year-old woman. Three days after admission for persistent chest pains, the patient suddenly developed right hemiplegia, right homonymous hemianopsia, and aphasia. By diffusion-weighted magnetic resonance imaging and magnetic resonance angiography, we diagnosed acute-phase cerebral infarction caused by abrupt occlusion of the left middle cerebral artery by a thrombus, and treated it with intravenously administered tissue plasminogen activator. Three hours afterward, the patient's condition improved considerably. She was discharged 15 days after admission without any neurological sequelae. Thus, we show that takotsubo cardiomyopathy complicated by cerebral emboli can be successfully treated using tissue plasminogen activator. .