Alteration of Multiple Leukocyte Gene Expression Networks is Linked with Magnetic Resonance Markers of Prognosis After Acute ST-Elevation Myocardial Infarction

Prognostic relevant pathways of leukocyte involvement in human myocardial ischemic-reperfusion injury are largely unknown. We enrolled 136 patients with ST-elevation myocardial infarction (STEMI) after primary angioplasty within 12 h after onset of symptoms. Following reperfusion, whole blood was collected within a median time interval of 20 h (interquartile range: 15-25 h) for genome-wide gene expression analysis. Subsequent CMR scans were performed using a standard protocol to determine infarct size (IS), area at risk (AAR), myocardial salvage index (MSI) and the extent of late microvascular obstruction (lateMO). We found 398 genes associated with lateMO and two genes with IS. Neither AAR, nor MSI showed significant correlations with gene expression. Genes correlating with lateMO were strongly related to several canonical pathways, including positive regulation of T-cell activation (p = 3.44 x 10(-5)), and regulation of inflammatory response (p = 1.86 x 10(-3)). Network analysis of multiple gene expression alterations associated with larger lateMO identified the following functional consequences: facilitated utilisation and decreased concentration of free fatty acid, repressed cell differentiation, enhanced phagocyte movement, increased cell death, vascular disease and compensatory vasculogenesis. In conclusion, the extent of lateMO after acute, reperfused STEMI correlated with altered activation of multiple genes related to fatty acid utilisation, lymphocyte differentiation, phagocyte mobilisation, cell survival, and vascular dysfunction

Cardiac magnetic resonance assessment of central and peripheral vascular function in patients undergoing renal sympathetic denervation as predictor for blood pressure response

Background: Most trials regarding catheter-based renal sympathetic denervation (RDN) describe a proportion of patients without blood pressure response. Recently, we were able to show arterial stiffness, measured by invasive pulse wave velocity (IPWV), seems to be an excellent predictor for blood pressure response. However, given the invasiveness, IPWV is less suitable as a selection criterion for patients undergoing RDN. Consequently, we aimed to investigate the value of cardiac magnetic resonance (CMR) based measures of arterial stiffness in predicting the outcome of RDN compared to IPWV as reference. Methods: Patients underwent CMR prior to RDN to assess ascending aortic distensibility (AAD), total arterial compliance (TAC), and systemic vascular resistance (SVR). In a second step, central aortic blood pressure was estimated from ascending aortic area change and flow sequences and used to re-calculate total arterial compliance (cTAC). Additionally, IPWV was acquired. Results: Thirty-two patients (24 responders and 8 non-responders) were available for analysis. AAD, TAC and cTAC were higher in responders, IPWV was higher in non-responders. SVR was not different between the groups. Patients with AAD, cTAC or TAC above median and IPWV below median had significantly better BP response. Receiver operating characteristic (ROC) curves predicting blood pressure response for IPWV, AAD, cTAC and TAC revealed areas under the curve of 0.849, 0.828, 0.776 and 0.753 (p = 0.004, 0.006, 0.021 and 0.035). Conclusions: Beyond IPWV, AAD, cTAC and TAC appear as useful outcome predictors for RDN in patients with hypertension. CMR-derived markers of arterial stiffness might serve as non-invasive selection criteria for RDN

Rising utilization of coronary CT angiography across Europe over the last decade: insights from a large prospective European registry

Abstract Background/Introduction The recently updated 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes endorse the use of coronary computed tomography angiography (CCTA) for exclusion of obstructive coronary artery disease in patients with a low clinical likelihood (Class I, LOE B). Higher demand for CCTA requires broad availability, inevitably involving smaller healthcare providers, such as non-academic hospitals and private practices. Nevertheless, most published data on CCTA image quality and safety rely on exams performed in high-volume academic centers, and little is known about CCTA in non-academic settings. Purpose To investigate the utilization of CCTA across Europe over the last decade, focusing on differences between academic and non-academic centers. Methods We included patients with stable chest pain and suspected coronary artery disease (CAD) who received CCTA and were included in the European Society of Cardiovascular Radiology MR/CT registry 01/2010–01/2020. We compared CT equipment, image quality, radiation dose, the incidence of periprocedural adverse events, patient characteristics, and CCTA findings between academic (high volume university hospitals) and non-academic centers (non-academic hospitals and private practices). Results Overall, 64,317 patients (41.2% women; age 60±13 years) from 212 sites across 19 European countries were included. Academic centers submitted most cases in 2010—2014 (51.6%), whereas non-academic centers accounted for 71.3% of records in 2015–2020. While non-academic centers used less advanced technology, radiation dose remained low (4.54 [interquartile range (IQR) 2.28–6.76] mSv) with a 30% decline of high-dose scans (>7 mSv) over time. Diagnostic image quality was reported in 97.7% of cases, and the rate of acute scan-related events was low (0.4%) (Figure 1). From 2010–2014 to 2015–2020, CCTA nearly doubled in patients with low to intermediate pretest-probability, women >50, and 40–60 years old men (Figure 2). CAD presence and extent decreased slightly over time (prevalence: 2010–2014: 41.5% vs. 2015–2020: 40.6%), (multi-vessel disease in those with CAD: 2010–2014: 61.9% vs. 2015–2020: 55.9%; all p<0.01). Conclusion CCTA expands rapidly to non-academic centers across Europe, increasing availability while maintaining relatively low radiation dose, high diagnostic image quality, and safety. Broad availability of high-quality CCTA is essential for a successfully implementation of the recently updated guidelines for the diagnosis and management of chronic coronary syndromes. Funding Acknowledgement Type of funding sources: None. Changes in CCTA utilizationChanges in patient characteristic

Accuracy of cardiovascular magnetic resonance in myocarditis: comparison of MR and histological findings in an animal model

Background: Because Endomyocardial Biopsy has low sensitivity of about 20%, it can be performed near to myocardium that presented as Late Gadolinium Enhancement (LGE) in cardiovascular magnetic resonance (CMR). However the important issue of comparing topography of CMR and histological findings has not yet been investigated. Thus the current study was performed using an animal model of myocarditis. Results: In 10 male Lewis rats Experimental Autoimmune myocarditis was induced, 10 rats served as control. On day 21 animals were examined by CMR to compare topographic distribution of LGE to histological inflammation. Sensitivity, specificity, positive and negative predictive values for LGE in diagnosing myocarditis were determined for each segment of myocardium. Latter diagnostic values varied widely depending on topographic distribution of LGE and inflammation as well as on the used CMR sequence. Sensitivity of LGE was up to 76% (left lateral myocardium) and positive predictive values were up to 85% (left lateral myocardium), whereas sensitivity and positive predictive value dropped to 0 - 33% (left inferior myocardium). Conclusions: Topographic distribution of LGE and histological inflammation seem to influence sensitivity, specifity, positive and negative predictive values. Nevertheless, positive predictive value for LGE of up to 85% indicates that Endomyocardial Biopsy should be performed "MR-guided". LGE seems to have greater sensitivity than Endomyocardial Biopsy for the diagnosis of myocarditis

Subendocardial contractile impairment in chronic ischemic myocardium: assessment by strain analysis of 3T tagged CMR

<p>Abstract</p> <p>Background</p> <p>The purpose of this study was to quantify myocardial strain on the subendocardial and epicardial layers of the left ventricle (LV) using tagged cardiovascular magnetic resonance (CMR) and to investigate the transmural degree of contractile impairment in the chronic ischemic myocardium.</p> <p>Methods</p> <p>3T tagged CMR was performed at rest in 12 patients with severe coronary artery disease who had been scheduled for coronary artery bypass grafting. Circumferential strain (C-strain) at end-systole on subendocardial and epicardial layers was measured using the short-axis tagged images of the LV and available software (Intag; Osirix). The myocardial segment was divided into stenotic and non-stenotic segments by invasive coronary angiography, and ischemic and non-ischemic segments by stress myocardial perfusion scintigraphy. The difference in C-strain between the two groups was analyzed using the Mann-Whitney U-test. The diagnostic capability of C-strain was analyzed using receiver operating characteristics analysis.</p> <p>Results</p> <p>The absolute subendocardial C-strain was significantly lower for stenotic (-7.5 ± 12.6%) than non-stenotic segment (-18.8 ± 10.2%, p < 0.0001). There was no difference in epicardial C-strain between the two groups. Use of cutoff thresholds for subendocardial C-strain differentiated stenotic segments from non-stenotic segments with a sensitivity of 77%, a specificity of 70%, and areas under the curve (AUC) of 0.76. The absolute subendocardial C-strain was significantly lower for ischemic (-6.7 ± 13.1%) than non-ischemic segments (-21.6 ± 7.0%, p < 0.0001). The absolute epicardial C-strain was also significantly lower for ischemic (-5.1 ± 7.8%) than non-ischemic segments (-9.6 ± 9.1%, p < 0.05). Use of cutoff thresholds for subendocardial C-strain differentiated ischemic segments from non-ischemic segments with sensitivities of 86%, specificities of 84%, and AUC of 0.86.</p> <p>Conclusions</p> <p>Analysis of tagged CMR can non-invasively demonstrate predominant impairment of subendocardial strain in the chronic ischemic myocardium at rest.</p

Clinical characteristics and role of early cardiac magnetic resonance imaging in patients with suspected ST-elevation myocardial infarction and normal coronary arteries

A variety of conditions other than acute myocardial infarction may cause ST-elevation. Our objective was to evaluate the impact of cardiac magnetic resonance (CMR) on differential diagnosis from a prospective series of patients with suspected ST-elevation myocardial infarction (STEMI) and completely normal coronary arteries. Among 1,145 patients with suspected STEMI, 49 patients had completely normal coronary arteries and entered a prospective registry. CMR was done within 24 h, if possible, and included function analyses, T2-weighted imaging (T2 ratio), T1-weighted imaging before and after gadolineum administration (global relative enhancement; gRE), and late gadolineum enhancement (LGE). All patients were asked for a follow-up CMR after approximately 3 months. The incidence of patients with suspected STEMI and normal coronary arteries was 4.3% and mean age was 45 ± 14 years (STEMI group 64 ± 13 years; P < 0.001). 55% had a recent history of infection. Cardiac biomarkers showed a moderate elevation on admission. There was a significant change from baseline to follow-up for LV end-diastolic volumes (EDV) (P < 0.001), LV mass (P < 0.05), mean T2 ratio (P < 0.05), and LGE volume (P < 0.05). Major diagnostic groups were myocarditis (29%), pericarditis (27%), and takotsubo cardiomyopathy (10%). 18% were regarded as non-diagnostic. The study showed an incidence of 4.3% of patients with suspected STEMI and completely normal coronary arteries. Early CMR was valuable in the evaluation of the differential diagnoses and to exclude myocardial abnormalities in patients with uncertain aetiology. Further studies are needed for the assessment of long-term outcome