Endomyocardial fibrosis presenting as apical calcification and infective endocarditis

A 46-year-old woman was admitted for suspected infective endocarditis. Echocardiography showed a mobile mass attached to the thickened endocardium of the left ventricular apex. Histological examination showed extensive endomyocardial fibrosis

15O-labeled Water is the Best Myocardial Blood Flow Tracer for Precise MBF Quantification

Oxygen-15-labeled water (15O-H2O) is used as a radiopharmaceutical tracer with positron emission tomography (PET). Its short radioactive half-life permits consecutive rest and stress imaging acquisition while requiring an on-site cyclotron near a PET imaging system. 15O-H2O PET has the disadvantage of being less than ideal for visual assessment; however, its high extraction fraction allows for highly accurate quantification of myocardial blood flow (MBF). Therefore, 15O-H2O is considered to be a gold standard for MBF quantification. This is one of the great advantages of 15O-H2O PET over other PET myocardial perfusion imaging modalities. The purpose of this review is to provide the advantages and characteristics of 15O-H2O PET

Elevated serum endothelin-1 is an independent predictor of coronary microvascular dysfunction in non-obstructive territories in patients with coronary artery disease

Endothelin-1 contributes to the constrictor response of the coronary arteries in patients with ischemia with normal coronary arteries. There is thus increasing evidence that endothelin-1 plays a role in coronary microvascular dysfunction (CMD). We investigated whether elevated endothelin-1 is associated with CMD in patients with coronary artery disease (CAD). We prospectively studied 49 consecutive CAD patients with 1- or 2-vessel disease (age 71 +/- 10 years, 43 males). Myocardial blood flow (MBF) was measured by O-15-water PET/CT at rest and during stress, and the coronary flow reserve (CFR) was calculated by dividing the stress MBF by the rest MBF. A CFR of less than 2.0 in non-obstructive regions was defined as a marker of CMD. Eighteen out of 49 (37%) CAD patients had CMD. Endothelin-1 in patients with CMD was significantly higher than in those without CMD (2.27 +/- 0.81 vs. 1.64 +/- 0.48 pg/mL, P = 0.001). Accordingly, univariate ROC analysis showed that the continuous endothelin-1 levels significantly discriminated between the presence and absence of CMD (area under the curve = 0.746 [95%CI 0.592-0.899]). The dichotomous treatment of elevated endothelin-1 as 1.961 pg/mL or more yielded the optimal discriminatory capacity, with a sensitivity of 72.2% and a specificity of 71.0%. High endothelin-1 was still a significant predictor of CMD after adjusting for diabetes mellitus (odds ratio = 6.64 [1.75-25.22], P = 0.005). Endothelin-1 is associated with CMD in non-obstructive territories in patients with CAD, suggesting that endothelin-1 is a potential target for treating CMD in CAD patients

Critical Takotsubo Cardiomyopathy Complicated by Ventricular Septal Perforation

An 81-year-old woman was admitted with chest pain. An electrocardiogram demonstrated ST segment elevation in leads II, III and aVF, and echocardiography revealed left ventricular apical asynergy with a left-to-right ventricular shunt. Meanwhile, emergent coronary angiography showed no significant coronary artery stenosis, whereas left ventriculography indicated apical ballooning and a left-to-right ventricular shunt. We therefore diagnosed the patient with Takotsubo cardiomyopathy complicated by ventricular septal perforation and cardiogenic shock. An electrocardiogram disclosed a prolonged QT interval over time, and the patient became hemodynamically stable under treatment with inotropes; however, she suddenly developed fatal ventricular fibrillation three days after hospitalization. Takotsubo cardiomyopathy complicated by ventricular septal perforation is a critical condition that requires careful monitoring

Extracorporeal Membrane Oxygenation for COVID-19-Associated Acute Respiratory Distress Syndrome: A Nationwide Analysis

Extracorporeal membrane oxygenation (ECMO) has been used for COVID-19-associated acute respiratory distress syndrome (ARDS). We aimed to elucidate the association between ECMO and mortality in patients with COVID-19-associated ARDS in the nationwide setting. United States National Inpatient Sample was used to identify mechanically ventilated adults for COVID-19 with ARDS. We divided them into three groups according to the use of ECMO (i.e., no-ECMO, venovenous [VV]-ECMO, and venoarterial [VA]-ECMO). The primary outcome was in-hospital mortality, while the secondary outcomes included the length of hospital stay (LOS) and the total costs during hospitalization. We performed a stepwise logistic regression, adjusting for baseline characteristics, comorbidities, and severity. We included 68 795 (mean age [SD]: 63.5 [0.1]), 3280 (mean age [SD]: 48.7 [0.5]), and 340 (mean age [SD]: 43.3 [2.1]) patients who received no-, VV-, and VA-ECMO, respectively. The logistic regression analysis did not show significant associations between the use of VV-/VA-ECMO and mortality (adjusted odds ratio with no-ECMO as reference [95% confidence interval]: 1.03 [0.86-1.24] and 1.18 [0.64-2.15], respectively). While LOS was longest with VV-ECMO, the total costs were highest with VA-ECMO. In conclusion, our study found no association between the use of ECMO and mortality of COVID-19-associated ARDS in the nationwide setting

Prognostic value of phase analysis on gated single photon emission computed tomography in patients with cardiac sarcoidosis

Background We aimed to determine the correlation between phase analysis, reflecting the heterogeneity of perfusion defects, and the dyssynchrony of the left ventricle wall motion, and adverse cardiac events in cardiac sarcoidosis (CS) patients. Methods Fifty-seven consecutive patients with diagnosed CS (64 [IQR 55-71] years old, 14 males), who underwent F-18-FDG PET/CT and ECG-gated SPECT, were studied. FDG PET was analysed to measure cardiac metabolic volume (CMV), and total lesion glycolysis (TLG). The SPECT findings, such as LVEF, Summed Rest Score (SRS), bandwidth (BW) were evaluated. Results The median of BW was 56 degrees (IQR 40-95). BW showed a strong inverse correlation with LVEF (r = - 0.60, P 56 degrees) than the low BW group (BW <= 56 degrees) (15.1%/years vs. 4.4%/years, P = 0.025). In multivariable analysis, BW was a significant independent predictor of MACE (P = 0.015). Conclusion Phase analysis on gated SPECT was a significant and independent predictor of MACE in patients with CS

Progressive left ventricular dysfunction and myocardial fibrosis in Duchenne and Becker muscular dystrophy : a longitudinal cardiovascular magnetic resonance study

This study examined the progression of left ventricular dysfunction and myocardial fibrosis in patients with Duchenne muscular dystrophy (DMD) or Becker muscular dystrophy (BMD) to evaluate the effects of angiotensin-converting enzyme inhibitor (ACEI). Ninety-eight cardiovascular magnetic resonance (CMR) studies in 34 consecutive patients with DMD (n=21) or BMD (n=13) were retrospectively reviewed. Left ventricular ejection fraction (LVEF) and the extent of myocardial late gadolinium enhancement (LGE) were semiautomatically quantified. During the study period, 5 patients had already been treated with ACEI at the first CMR; 5 were started on ACEI at LVEF≥55% and 10 at LVEF<55%. All patients had hyperenhanced myocardium on LGE images at the first CMR (median extent, 3.3%; interquartile range, 0.1%-14.3%). A mixed-effects model for longitudinal data of each patient, adjusted for age, type of muscular dystrophy, steroid use, and ACEI use, showed that higher age (β=-1.1%/year; 95% confidence interval [CI], -1.8% to -0.4%; p=0.005) and no use of ACEI (β=-3.1%; 95% CI; -5.4% to -0.8%; p=0.009) were significantly associated with a lower LVEF. When ACEI use was stratified by time of initiation (LVEF≥55% vs. <55%), only ACEI initiation at LVEF<55% had a beneficial effect on LVEF at each imaging examination (β=3.7%; 95% CI, 0.9% to 6.4%; p=0.010). ACEI use or the time of initiation of ACEI did not significantly affect age-related increase in LGE. Conclusion: ACEI attenuated the age-related decline in LVEF only in patients with DMD or BMD and reduced LVEF, suggesting that further investigation on prophylactic use of cardioprotective therapy in these patients is warranted

Advances in Diagnostic Imaging for Cardiac Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown etiology, and its clinical presentation depends on the affected organ. Cardiac sarcoidosis (CS) is one of the leading causes of death among patients with sarcoidosis. The clinical manifestations of CS are heterogeneous, and range from asymptomatic to life-threatening arrhythmias and progressive heart failure due to the extent and location of granulomatous inflammation in the myocardium. Advances in imaging techniques have played a pivotal role in the evaluation of CS because histological diagnoses obtained by myocardial biopsy tend to have lower sensitivity. The diagnosis of CS is challenging, and several approaches, notably those using positron emission tomography and cardiac magnetic resonance imaging (MRI), have been reported. Delayed-enhanced computed tomography (CT) may also be used for diagnosing CS in patients with MRI-incompatible devices and allows acceptable evaluation of myocardial hyperenhancement in such patients. This article reviews the advances in imaging techniques for the evaluation of CS